HomeMy WebLinkAbout2012-202 11 • x • 12
GRANT APPLICATION 15A
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FLORIDA DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services
Complete all items
ID. Code (The State Bureau of EMS wiU assign the ID Code — leave this blank) C
1. Counq Name: Indian River County
Business Address: 180127"' Street Vero Beach Florida 32960
Telephone : 772 2264900
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 . E�
EMS county grant application and its attachments are true and correct . My s ' *° .,•
acknowledges and assures that the County shall comply fully with the con s .9
outlined in the FI ida EMS County Grant Application . , ;'
Signature : C Lc>/Ulf Date . 11-0640009 s
Printed Name: Gq2 C . Wheeler
go
Position Title : Chairman, Board of County Commissioners • �yAy �
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3. Contact Person : (The individual with direct knowledge of the project on a day- -
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 43ra Avenue Vero Beach Florida 32966
Telephone : 772 226-3864 Fax Number: 772 2264868
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
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 NIA
TOTAL FICA NIA
Grand total Salaries and FICA NIA
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 quantityAmount
NIA
TOTAL NIA
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
Fire Manager Schedule Program 2 year subscription $ 159840.00
TOTAL $ 159840. 00
GRAND TOTAL $ 159840.00
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 : 1800 2r Street Vero Beach Florida 32960 ••• oSS�ONERS;# ;
. .
o :
Federal Identification number VF 59-6000674 � . ¢;
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Authorized Official : G Gt�� _ : = : � _
a
//Signature Date
Gary C. eeler, Chairman Board of County Commissimi's, . ., •���4°
Type Name and Title •; � ; °a
rrnwussnuo "y"„ A
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
64-25-60-00-000 N N2000 7
Federal Tax ID : VF_ _ _ _ _ _ _ _ _
Grant Beginning Date: October 1 , Grant Ending Date: September 30,
DN Form 1767P, Rev, June 2002
RESOLUTION NO. 2012-01 ESD
A RESOLUTION OF THE EMERGENCY SERVICES DISTRICT BOARD OF
COMMISSIONERS, INDIAN RIVER COUTY, FLORIDA, AUTHORIZING THE
APPLICATION FOR FUNDING COUNTY EMERGENCY MEDICAL SERVICES
(EMS) GRANT AWARDS TO BE SUBMITTED TO THE STATE OF FLORIDA
DEPARTMENT OF HEALTH, BUREAU . OF EMERGENCY MEDICAL
SERVICES,
WHEREAS, The Florida Departments of Health, Bureau of Emergency Medical Services announced that
applications for funding County Emergency Medical Services (EMS) Grant awards are now being accepted and a
grant application has been prepared for Indian River County; and
WHEREAS, an application for grant funds for fiscal year 2012/ 13 has been prepared by the County; and
NOW, THEREFORE, BE IT RESOLVED BY THE EMERGENCY SERVICES DISTRICT BOARD OF
COMMISSIONERS OF INDIAN RIVER COUNTY, FLORIDA, that the Chairman is authorized to sign and
execute the application for EMS grant funds certifying that monies from the EMS Grant Program For Counties will
improve and expand the County' s pre-hospital EMS system and that the funds will not be used to supplant existing
County EMS budget allocations.
The foregoing Resolution was offered by Commissioner p 1 Bryan
Who moved its adoption. The motion was seconded by Commissioner Wheel. er and, upon being put to a
vote, the vote was as follows :
Chairman, Gary C. Wheeler.
Vice Chairman, Peter D . O'Bryan Ave
Commissioner Bob Solari Aye
Commissioner Joseph E. Flescher Ave
Commissioner Wesley S. Davis Aye
The Chairperson thereupon declared the resolution duly passed and adopted this 06 day of
November , 2012.
EMERGENCY SEVICES DISTRICT
BOARD OF COMMISSIONERS pN�RS °•°°°
INDI COUNTY, FLORIDA e gs�5' ' •. O
BY: a 'Rot
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G& C. Wheeler, Chairman
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J Ppt+ : Je nu , Cler , a°11pIND
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STATE OF FLORIDA ---1 e \�S�DNE S+
Approved as to form and legal INDIAN RIVER COUNTY ,° p�;•• ' •
suffi ' e4 THIS IS TO CERTIFY THAT THI S •
A TRUE AND CO RE T COP OF ' ~
THE ORIGINA N FILE IN
BY OFFICE
William K. eBraal
Assistant County Attorney Y T e D.c. •�`.Vo tt . � ':;'�`
DATE � � / � °°• °••• C�
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