HomeMy WebLinkAbout2014-188GRANT APPLICATION
FLORIDA DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services
Complete all items
111181x.01.4
IS -.A.; .
cOt4-- lrQ
ID. Code (The State Bureau of EMS will assign the ID Code — leave this blank) C
1. County Name: Indian River County
Business Address: 1801 27t'' 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 the Florida ESS County Grant Ap oJi 1�,,
u p�,•
Sigma+ro: ��� _ . r Date:
r�o •*.11-18-14
•
ssners
Printed Name: Wesley S. Davis
Position Title: Chairman, Board of County
3. Contact Person: (The individual withp -.1 +' ledgg,df the project on a day-to-
day basis and has responsibility for the imp(; _tib?the grant activities. This
person is authorized to sign project reports a• •'arequest project changes. The
rf
signer and the contact person may be the same.)
Name: Brian S. Burkeen
Position Title: Assistant Chief
Address: 4225 43`d Avenue Vero Beach Florida 32966
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.
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
N/A
TOTAL
N/A
TOTAL Salaries
N/A
TOTAL FICAN/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 cateaorvl.
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
New World Systems Inventory System
$ 25,048.00
TOTAL
$ 25,048.00
GRAND TOTAL
$ 25,048.00
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 27th Street Vero Beach Florida 32960
Federal Identification number VF 59-6000674
Authorized Officia
Signature Date
„,.� • Chairman Board of County Commissioners
..1'� O'' MIS
--
..• � s%' Wesley S Davis, Chairman
`.' St i`k and return this page with your application to:
5
*: * : Florida Department of Health
1. BEMS Grant Program
\%.. �, • o7 4052 Bald Cypress Way, Bin C18
V.7 . oQa Tallahassee, Florida 32399-1738
Do ndt� k v this line. For use by Bureau of Emergency Medical Services personnel only
11-18-14
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
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
N/A
TOTAL
N/A
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 cateaorv).
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 exsected life of one 1 ear or more.
List the item and, if applicable, the quantity
Amount
New World Systems Inventory System
$ 25,048.00
TOTAL
$ 25,048.00
GRAND TOTAL
$ 25,048.00
DH Form 1684, Rev June 2002