HomeMy WebLinkAbout2010-028 1 ' 1� J ' [
GRANT APPLICATION
FLORIDA DEPARTMENT OF HEALTH
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 : 1800 27 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 thM " - MV�P -
EMS y Grant Application .
Sign ture : Date : January 19 , 2010
Printed Name : Peter D . O ' Br a
Position Title : Chairman , Board of County Commissioners
3 . Contact Person : (The individual with direct knowledge of the project on a day-to-
day basis and has responsibility for the implementation of the grant activities . This
person is authorized to sign project reports and may request project changes . The
signer and the contact person may be the same . )
Name : Brian S . Burkeen
Position Title : Assistant Chief
Address : 422543 rAvenue Vero Beach Florida 32966
Telephone : 772 226 -3864 I Fax Number: 772 226 -3868
E - mail Address : bburkeen@ircgov . 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 County 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 A-mount
Mobile Software AVL Dispatching
TOTAL 51 , 112 . 00
GRAND TOTAL 519112 . 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 ,
Mailing Address : 180027 th Street Vero Beach Florida 32960
Federal Identification Bumber VF 59 =6000674
Authorized Official : � � January 19 , 2010
Signature Date
Peter D . O ' Bryan, Chairman Board of County Commissioners_
Type Name and Title
Sign and return this page with your application to:
Florida Department of Health
BEMS Grant Program
4052 Bald Cypress Way, Bin C18
Tallahassee, Florida 32399- 1738
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
64-25-60-00-000 N N2000 7
Federal Tax ID : VF
Grant Beginning Date : October 1 , Grant Ending Date : September 30 ,
DH Form 1767P , Rev . June 2002
APPROVED A >
APPROVED AND L5i_a t • : 1
By ' �. .
. .. . :. . . . . : . . ... . .
GEORGE . Ge.
ASSISTANT COUNTY ia?
C ✓ (:ht Attest : J . K. Barton , Clerk
ountv : Iministrator
eputy Clerk