HomeMy WebLinkAbout2016-141 EMS COUNTY GRANT APPLICATION
FLORIDA DEPARTMENT OF HEALTH
Qp� � Emergency Medical Services.Program
Complete all items
ID. Code The State EMS Program will assign the ID Code— leave this blank C50
1. Count Name: Indian River Count
Business Address 1800 27th Street
Vero Beach, FL 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 coptracts,,,9rants, and other legal
documents for the county) I certify that all information and data in tf�i�;£IS9��`�3( t .,Grant application and
its attachments are true and correct. My signature acknowledges' d� ures
o. the County shall
comply fully with the conditions outlined in the Florida EMS Cou -Gr vp tio�r';
Signature: G Da* 09/13/2016
Qc.c.c
Printed Name Bob Solari e
Position Title. Chairman, Board of County Commis` rs
3. Contact Person: (The individual with direct knowledge of the proJec l�w. �. y-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 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 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 64J-1 015, F.A.0
ATTEST:
Jeffrey R. Smith Cl-erk of Cour and
Ccmptrol e
BY:
p y er
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 = $ 000
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
TrackEMS Mobile APP 21,867.00
Total Veh. & Equipment= $21,867.00
Grand Total = $21,867.00
DH 1684, December 2008
2
FLORIDA DEPARTMENT OF HEALTH
EMERGENCY MEDICAL SERVICES(EMS) GRANT SECTION
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
DOH Remit Payment To:
The agency name and mailing address must be in the state MyFloridaMarketPlace (MFMP) system.
Name of Agency: Indian River County Board of County Commissioners
Mailing Address: 1800 27th Street
Vero Beach, FL 32960
Federal Identification number: VF 59-60006764
Authorized County Official: ��.t,` 09/13/2016
Signature Date
Bob Solari, Chairman Board of County Commissioners
Type or Print Name and Title
Sign and return this page with your application to:
Florida Department of Health
Emergency Medical Services Section, 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: C50
Approved By
Signature of State EMS Grant Officer Date
State Fiscal Year: 2016 - 2017
Organization Code E.O. OCA Object Code Category
64-61-70-30-000 05 SF005 750000 059998
Federal Tax ID:VF
Grant Beginning Date: Grant Ending Date:
DH 1767P, December 2008 64J-1 015, F.A.0
3