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Home My WebLink About2022-258EMS COUNTY GRANT APPLICATION 2022 - 2023 FLORIDA DEPARTMENT OF HEALTH Emergency Medical Services Program Honaa I or A ■ulll� ■ Complete all items State EMS Program will assign the ID Code - leave this 1. Count Name: Indian River Count Business Address: 180027 th St. Vero Beach, FL 32960 Telephone: 772-226-3900 Federal fax ID Number (Nine Di it Number), VF,59,.69006764 2. Certification: (The applicant signatory who has;�pfh to sig► ntracts, grants, and other legal documents for the county) I certify that all informatirin a ata 1 tlai SMS county grant application and its attachments are true and cor t. My signatdre:ackn �ar�ssures that the county shall comply fully with the c nditi ou ne i rI�rida E ;5 Qnty meant Application. Signature: i °' Date: /Z- /3� 2OZ Printed Name: Jo h E r a Position Title: Chairman, Board of Count (,Gdmtfii4*k'nnprc 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: Stephen R. Greer Position Title: Bureau Chief of EMS Address. 4225 43rd Ave. Vero Beach, FL 32960 Telephone: 772-226-3951 Fax Number: 772-978-1820 E-mail Address: igreer@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 this resolution. 5. Organization List: Complete a budget page(s) for each organization, which at your option you will provide funds. List the organization(s) below. (Use additional pages if necessary) Attest: Jeffrey R. Smith, Clerk of DH 1684. Decemhar 9nnR tpo., i' d on10% rte:,... * _-4— 1 Deputy Clerk =ORM Y b4J-1.u1 A.N/ By _. ^0UNTY t\TT0RN BUDGET PAGE - When the budget form is in your computer, the budget totals below should be added for you if you place your cursor over a subtotal or total field, right click your mouse, then left click "Update Field" on the resulting menu. A. SalariP_c and Ranafifa- 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 excludina exnenditiirPs claccifintl as operatinq capital outlay see next category). List the item and, if applicable, the quantity Amount I Total Expenses - I 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 nnrn,ai PYnPrfari fifa r r or more. List the item and, if applicable, the quantity _4=:Amount auma HAL S3040.100 36,014.00 I Total Vehicles & Equipment = $ 0.00 Grand Total = $ 36,014.00 nu in n 2 FLORIDA DEPARTMENT OF HEALTH EMERGENCY MEDICAL SERVICES (EMS) GRANT UNIT 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 county name, address, and corresponding federal ID number used herein must be in the state MyFloridaMarketPlace (MFMP) system. A finance person in your organization who does business with the state can provide these. Name of County: Indian River County Board of County Commissioners Mailing Address: 1800 27" Street Vero Beach, FL 32960 J/ f Federal 9 -digit Identification number: VF 59-60006764 ; = 3 -digit seq. code 070 Authorized County Official: _ '' C Si4aatwre Date Joseph Earman Chairman Type or Print Name and Title Attest: Jeffrey R. Smith, Clerk of Sign and return this page with your application to: APPROVED AS �TO FOR Circuit Court and Comptroller A ND LEGAL S C }= F i G I E N i Florida Department of Health ��.�� Emergency Medical Services Unit, Grants BY 4052 Bald Cypress Way, Bin A-22 Deputy L - N �R�E� INGO— L0Tallahassee, Florida 32399-1722 OOUAN AIFTORNEY Do not write below this line. For use by State Emergency Medical Services Section Grant Amount for State to Pay: $ _Approved By: Approved By: Signature of State EMS Unit Supervisor Signature of Contract Manager State Fiscal Year: 2022 - 2023 Grant ID: Code: Organization Code E.O. OCA Object Code 64-61-70-30-000 05 SF005 751000 Federal Tax ID: VF _ _ _ — _ _ _ Seq. Code: Grant Beginning Date: Grant Ending Date: Date Date Category 059998 DH 1767P, December 2008 (rev. June 8, 2018), incorporated by reference in F.A.C. 64J-1.015. 3 Instructions: County Government Application Form 2022-2023 The first application page has five numbered items. Please note that Item 2 on the first application page is where the county's authorized person must provide his/her signature and the date Item 4 describes the content of the current "resolution" that is required. However, if a previous resolution has continuing authority, include a signed message about this and provide a copy of the previous resolution. Item 5 of the first page of the application form asks for the name of the organization(s) to which you decide to allocate funds from your new county grant. The second page of the application form is the budget page, and one of these budget pages is needed for each organization listed in item 5. The county alone has the authority to use all the grant funds itself or to provide some of the funds to other organizations within the county. However, the county remains responsible to the state for all the funds. The budget costs must total to the exact amount of new funds for your grant. You can request budget changes and to add to the new grant budget unexpended previous funds from the prior grant, after the new grant begins. The Request for Grant Fund Distribution Form is the last page herein and you must complete only the top part of the form. State EMS will complete the bottom part, as stated on the form. You should copy all forms on your computer to use them. If you place them in restricted editing mode, you can use your keyboard Tab key to go from field to field.