HomeMy WebLinkAbout2015-239EMS COUNTY GRANT APPLICATION
FLORIDA DEPARTMENT OF HEALTH
Emergency Medical Services Program
Complete all items
ID. Code (The State EMS Program will assign the ID Code – leave this blank) C40
1. County Name: Indian River County
Business Address 1800 27th Street
Vero Beach, FL 32960
Address' 4225 43rd Avenue
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'couiltygr' t pplication and
its attachments are true and correct. My signature acknowledges and autres thane E.ounty shall
comply fully with the con s outlined i%4he FloridaoELMS County Graix€A�atib�ra.
Signature: •
J..J c—C p,.C.a �; 404 = ! - e Deceither 8 , 20
do ,.\fi.
Printed Name. Bob Solari
Position Title Chairman, Board of County Commissionerk•
t` ,„ .
3. Contact Person: (The individual with direct knowledge of the project ort-itiAti...§icray 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 Burkeen
Position Title Assistant Chief
Address' 4225 43rd Avenue
Vero Beach, FL 32967
Telephone. 772-226-3864
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 We cannot process for funds without a current resolution
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 1684, December 2008
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DH 1684, December 2008
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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 =
$ 0 00
TOTAL FICA & Other Benefits =
Total Salaries & Benefits =
$ 0.00
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
Total Expenses =
$ 0.00
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
Mobile Software AVL Dispatching
45,920.00
Total Veh. & Equipment =
$ 0.00
Grand Total =
$ 0.00
DH 1684, December 2008
2
FLORIDA DEPARTMENT OF HEALTH
EMERGENCY MEDICAL SERVICES (EMS) GRANT PROGRAM
REQUEST FOR GRANT FUND DISTRIBUTION
In accordance with the provisions of Section 401.113(2) (a), Florida Statutes, the undersigned hereby requests
an EMS grant fund distribution for the improvement and expansion of pre -hospital EMS. `o
DOH Remit Payment To:
Name of Agency. Indian River County Board of County Commissoners
Mailing Address: 1800 27th Street
Vero Beach, FL 32960
Federal Identification number: VF 59-60006764
Authorized County Official.
r _
?o
i*; Sign and return this page with your application to:
nprPmhPr R, 7n15
Signature Date
Bob Solari, Chairman Board of County Commissoners
Type or Print Name and Title
•........•••
Florida Department of Health
Emergency Medical Services Program, Grants
4052 Bald Cypress Way, Bin A-22
Tallahassee, Florida 32399-1722
Do not write below this line. For use by State Emergency Medical Services Program
Grant Amount For State To Pay: $ Grant ID: Code: C40
Approved By :
Signature of State EMS Grant Officer Date
State Fiscal Year: 2015 - 2016
Organization Code E.O.
64-61-70-30-000 05
Federal Tax ID: VF
OCA
SF005
Grant Beginning Date:
Object Code
750000
Grant Ending Date:
Category
059998
DH 1767P, December 2008
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