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V <br />D� <br />REQUEST FOR COUNTY GRANT DISTRIBUTION (ADVANCE PAYMENT) <br />EMERGENCY MEDICAL SERVICES (EMS) <br />COUNTY GRANT PROGRAM <br />in accordance wf[h orae provisions of seaan 401.113(2)(e), +.s., the ix,dersowd hereby <br />requests an Eus corxuy V%1= <br />ofprohospitaj=nt) for the improvement and <br />Payment To: Indian River County Board of Count Cor7riissioners <br />ame of boardo ours y ommissioners ayee <br />1840 25th Street <br />Address <br />Vero Beach. FL 32900 <br />ore p <br />Tax ID Numberof county: 6 9 6 0 0 0 6 7 4 <br />Authorizing County Official <br />Date: 12-12-2ti00 <br />Name- FraU L1, AdnmN Title: Chairman, Board of County Compussioi <br />SIGN AND RETURN WITH YOUR GRANT APPUCATION TO: <br />Department of Health <br />Bureau ofATS'�Oenc Medical Services <br />ur► Grants <br />2020 CapitCi a SFBin C18 <br />Tallahassee, Florida 3399-1738 <br />For Use Only by Department of Wealth, <br />Bureau of Emergency Medica! Services <br />Grant Number; <br />Approved By: Date: <br />igna ure, State EMS Uranticer <br />Year.• <br />ition Code EQ. <br />Tax I.D. V F— „—,—,--- — <br />rg Date: <br />4 <br />ff.1 <br />Ending Date: <br />