HomeMy WebLinkAbout2011-211 GRANT APPLICATION ep
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GE. RTIFICA110N ON i a ;7 r CAGE
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1K , BARTOW CLERK
FLORIDA DEPARTMENT OF HEALTH f — C
Bureau of Emergency Medical Services
IJ 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 : 180027 in Street Vero Beach Florida 32960
Telephone : (772 226 -3900
Federal Tax ID Number ( Nine Digit Number) . VF 59 as 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 sig � 04NF s
acknowledges and assures that the County shall comply fully with the condi
outlined in the Florida EMS County Grant Application .
Signature : Date : 10 - 04 - • o °,
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Printed Name : Bob Solari io - � -�� ;w;
Position Title : Chairman , Board of County Commissioners s
3 . Contact Person : (The individual with direct knowledge of the project on a d ? NF
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 : 4225 43 " Avenue Vero Beach Florida 32966
Telephones (772).. 226=a3864 Fax Number: 772) 226 -3868
E- 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 County Fire Rescue
DH Form 1684 , Rev. June 2002
A TRUE COPY
GERTIH )UTION ON LAST PAGE
J . K . BfIRTON G ERK
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
ex enditures classified as operating capital outlay ( see next cate o ) .
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
Portable Freezers for Post Arrest Hypothermia Protocol $ 20 , 250 . 00
TOTAL $ 20 , 250 . 00
GRAND TOTAL $ 201250M
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 : 1800 27th Street Vero Beach Florida 32960
Federal Identification number VF 59-6000674 C0 �1Mis.s
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Authorized Official :
Signature Daite ? •' o
Bob Solari Chairman Board of County Comifiisiione
Type Name and Title
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Sign and return this page with your application to: •''9 � COIa•�°
Florida Department of Health ob anamunze•
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 Dersonnel 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 Object 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
NATE OF FLORIDA —�_ ••• COM
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