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Odd
EACH
EMS 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) C60
1. County Name: Indian River County
Business Address: 1800 27th Street
Vero Beach, FL 32960
Vero Beach, FL 32967
Telephone: 772-226-3900
Federal Tax ID Number (Nine Digit Number): VF 59-60006764
2. Certification: (The applicant signatory who has authority tc4i
documents for the county) I certify that all information and dab; ifrthi
its attachments are true and correct. My signature acknowlei0s an
comply fully with the conditi outlined iy' e FLer• F lS tnty
Signature:
U� ti
corrhaP1TY�4c•'grants, and other legal
S cdufr,.grant application and
suretatthe county shall
cam.
gate: November 14 , 2017
Printed Name:
Position Title: chairman, Board of County Commms
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3. Contact Person: (The individual with direct knowledge of the project on a day-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: Cory S. Richter
Position Title: Battalion Chief
Address: 4225 43rd Avenue
Vero Beach, FL 32967
Telephone: 772-226-3863 Fax Number: 772-226-3868
E-mail Address: crichter@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)
DH 1684, December 2008
64J-1.015, F.A.C.
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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
King Vision Laryngoscopes and Blades
$24,659.00
Total Expenses =
$ 24,659.00
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
Total Vehicles & Equipment =
$ 0.00
Grand Total =
$ 24,659.00
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 Pavment To:
The agency name, address, and federal ID number must be in the state MyFloridaMarketPlace (MFMP)
system. Ask a finance person who does business with the state for your organization to provide these.
Name of Agency: Indian River County Board of County Commissioners
4.4
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Mailing Address: 1800 27th Street
9
Vero Beach FL 32960 �,iY COnjl
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Federal Identification number: VF 59-60006764p
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Authorized County Official: :' 1/14/2017
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igna ure •• Dpfe i
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Joseph E. Flescher . Chairman ......
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Type or Print Name and Title
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Sign and return this page with your application to:
W
Florida Department of Health
Fi
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: C60
Approved By:
Signature of State EMS Grant Officer Date
State Fiscal Year: 2017 - 2018
Organization Code E.O. OCA Obiect Code Cateaory
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.C.
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