HomeMy WebLinkAbout2013-220 151.&0 63
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GRANT APPLICATION
_FLORIDA - DEPARTMENT OF HEALT-H_ -- - -_ - _ - -- -- - --- - _ - - --
- - Bureau of Emergency Medical Services
Complete all items
ID. Code (The State Bureau of EMS will assign the ID Code - leave this blank) C
1 . County Name: Indian River County
Business Address . 1801 2r Street Vero Beach Florida 32960
Telephone : (772) 226-3900
Federal Tax ID Number ( Nine Digit Number) . VF 59 - 60006764
2. Certification : (The applicant signatory who has authority to sign contracts , grants ,
and other legal ' documents for the county) I certify that all information and data in this
EMS county grant application and its attachments are true and correct. My signature
acknowledges and assures that the County shall comply fully with the conditions
outlined in the F rida EW County Grant Application .
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Signature : °° ik " z, 5 - 0 I
Printed Na Jose h E. Flescher ,•`�.•• ' ' ' . 'yo
Position TitNror Chairman, Board of County C , 'on
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3. Contact Person : (The individual with direct knd el dge oj46n a day4o-
day basis and has responsibility for the implementd4iork of th ities . This
person is authorized to sign project reports and may' • anges. The
signer and the contact person may be the same . ) ""••NRIVER „,�••°
Name: Brian S. Burkeen
Position Title: Assistant Chief
Address : 4225 43m Avenue Vero Beach Florida 32967
Telephone : 772 226-3864 Fax Number: 772) 2264868
&mail Address : bburkeen irc ov.com
4. Resolution: Attach a current resolution from the Board of County Commissioners
certifying the grant funds will improve and expand the county pre-hospital EMS system
and will not be used to supplant current levels of county expenditures .
5. Budget: Complete a budget page(s) for each organization to which you shall provide
funds .
List the organization( s) below. (Use additional pages if necessary)
Indian River Cou Fire Rescue
DH Form 1684, Rev. June 2002
BUDGET PAGE
A. Salaries and Benefits :
For each position title , provide the amount of salary per hour, FICA per hour, other
fringe benefits , and the total number of hours. Amount
TOTAL Salaries N/A
TOTAL FICA N/A
Grand total Salaries and FICA N/A
B. Expenses: These are travel costs and the usual, ordinary, and incidental expenditures
by an agency , such as, commodities and supplies of a consumable nature excluding
expenditures classified as operating capital outlay see next category).
List the item and, if applicable, the quantity Amount
N/A
TOTAL N/A
C. Vehicles, equipment, and other operating capital outlay means equipment, fixtures , and
other tangible personal property of a non consumable and non expendable nature with a
normal expected life of one 1 year or more .
List the item and, if applicable, the quantity Amount
13 King Vision Video Laryngoscope and accessories $ 17,439.00
TOTAL 1 $179439.00
GRAND TOTAL $179439.00
DH Form 1684, Rev. June 2002
DEPARTMENT OF HEALTH
EMS GRANT PROGRAM
REQUEST FOR GRANT FUND DISTRIBUTION
In accordance with the provisions of Section 401 . 113(2)(a) , F . S . , the undersigned
hereby requests an EMS grant fund distribution for the improvement and expansion of
pre-hospital EMS .
DOH Remit Payment To :
Name of Agency: Indian River County Board of County Commissioners
", COMM/ S
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Mailing Address : 1801 27Stmt Vero Beach Florida 32960 ,.��� • . • " ' " ' S •��
fee
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Federal Identification number VF 59=6000674
Authorized Official: 5
Signatur Date =?O�• O`
e h E. Flescher Chairman Board of CountyCommissione
Type Name and Titleof Stu
`"•• R COUNo""°°
Sign and return this page with your application to:
Florida Department of Health
BEMS Grant Program
4052 Bald Cypress Way, Bin C18
Tallahassee, Florida 323994738
Do not write below this line. For use by Bureau of Emergency Medical Services personnel only
Grant Amount For State To Pay: $ Grant ID: Code :
Approved By :
Signature of EMS Grant Officer Date
State Fiscal Year .
Organization Code E. O. OCA Obiect Code
64-25gso-00go000 N_ N2000 7
Federal Tax ID: VF_ _ _ _ _ _ _ _ _
Grant Beginning Date: October 1 , Grant Ending Date : September 30,
DH Form 1767P, Rev, June 2002
14
GRANT NAME : EMS County Awards Grant GRANT # N/A
AMOUNT OF GRANT: $ 17 439 . 00
DEPARTMENT RECEIVING GRANT: Fire Rescue
CONTACT PERSON : Brian Burkeen PHONE NUMBER : 772-226-3864
1 . How long is the grant for? 1 year Starting Date : FY 2013/ 14
2 . Does the grant require you to fund this function after the grant is over? Yes X No
3 . Does the grant require a match ? Yes X No
If yes, does the grant allow the match to be In Kind Services? (N/A ) Yes No
4 . Percentage of match N/A 0%
5 . Grant match amount required $ N/A
6 . Where are the matching funds coming from ( i .e. In Kind Services ; Reserve for Contingency)? N ?A
7 . Does the grant cover capital costs or start-up costs ? Yes X No
If no, how much do you think will be needed in capital costs or start up costs $
(Attach a detail listing of costs )
8 . Are you adding any additional positions utilizingthe grant funds? Yes No
If yes, please list. ( If additional space is neededXplease attach a schedule . )
Acct. Description Position Position Position Position Position
011 . 12 Regular Salaries N/A N/A N/A N/A N/A
011 . 13 Other Salaries & Wages (PT) N/A N/A N/A N/A N/A
012 . 11 Social Security N/A N/A N/A N/A N/A
012 . 12 Retirement-Contributions N/A N/A N/A N/A N/A
012 . 13 Insurance-Life & Health N/A N/A N/A N/A N/A
012 . 14 Worker= s Compensation N/A N/A N/A N/A N/A
012 . 17 S/Sec . Medicare Matching N/A N/A N/A N/A N/A
TOTAL N/A N/A N/A N/A N/A
9 . What is the total cost of each position including benefits , capital , start-up , auto expense, travel and operating?
Salary and Benefits Operating Costs Capital Total Costs
N/A N/A N/A N/A
N/A N/A N/A N/A
N/A N/A N/A N/A
N/A N/A N/A N/A
N/A N/A N/A N/A
10 . What is the estimated cost of the grant to the county over five years? $
Grant Other Match Costs Total
Amount Not overed Match
First Year $ N/A $ N /A $ N/A Second Year $ N/A $ N/A $ N/A
Third Year $ N/A $ N/A $ N/A $ N/A
Fourth Year $ N/A $ N/A $ N/A $ N/A
Fifth Year $ N/A $ N/A $ N/A $ N/A
Signature of Preparers Date : October 29 . 2012