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i <br /> ATTACHMENT A <br /> STATE OF FLORIDA - HAZARD MITIGATION GRANT PROGRAM <br /> MITIGATION PLANNING APPLICATION <br /> 1 . Applicant : Indian River County Department of Emergency Services <br /> 2 . State Legislative District(s ) : State Representative District 80 <br /> Congressional District(s ) : 15th Congressional District <br /> 3 . Federal Tax I . D . Number: 59-6000674 FIPS Code : (if your FIPS code is <br /> not known , please fill out FEMA Form 90-49 so that the Department may obtain a FIPS code for you ) <br /> 4 . Do you plan on using the Mitigation 20120 software? ❑ yes X no <br /> 5 . COUNTY POINT OF CONTACT TITLE : Director (Dept. of Emergency Services ) <br /> FIRST NAME : John MI : LAST NAME : King <br /> STREET ADDRESS : 1840 25th Street <br /> CITY: Vero Beach STATE : FL ZIP : 32960 <br /> TELEPHONE : (772 ) 567-8000 , Ext . 1225 FAX : (772 ) 567-9323 EMAIL : iking cDircgov . com <br /> 6 . Do you intend for the State to directly contract with a consultant? X rtes ❑ no <br /> 7 . If your county has identified a consultant to do your Mitigation Planning revisions please complete the following : <br /> 8 . POTENTIAL APPLICANT (CONSULTING ENTITY) : Treasure Coast Regional Planning Council <br /> POINT OF CONTACT TITLE : Executive Director <br /> FIRST NAME : Michael MI : J . LAST NAME : Busha <br /> STREET ADDRESS : 301 East Ocean Boulevard , Suite 300 <br /> CITY: Stuart STATE : FL ZIP : 34994 <br /> TELEPHONE : (772 ) 221 -4060 FAX : (772 ) 221 -4067 EMAIL : mbushaetcrpc . org <br /> 9 . COUNTY'S DULY AUTHORIZED REPRESENTATIVE" ( proof of authorization to sign contracts required ) : <br /> TITLE : Chairman FIRST NAME : Kenneth R. LAST NAME : Macht <br /> STREET ADDRESS : 1840 25th Street <br /> CITY: Vero Beach STATE : FL ZIP : 32960 <br /> TELEPHONE : 77 67-800 90 FAX : (772 ) 770-5334 <br /> SIGNATURDATE : May 6 . 2003 <br /> 'INDIVIDUAL LEGAL SIGN G AU AORITVAOi TH RESPECTIVE COUNTY (e.g., THE CHAIRPERSON, BOARD OF COUNTY <br /> COMMISSION OR THEIR DESIGNEE) <br />