HomeMy WebLinkAbout2008-411 1
GRANT APPLICATION
FLORIDA DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services
Complete all items
ID. Code he State Bureau of EMS will assign the ID Code leave this blank)
1 . County Name: Indian River County
Business Address : 1800 27 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 Iegol 'documents for the county) I certify that all information and data in this
E AIIS cW ttyj_ra' nt'application and its attachments are true and correct . My signature
acknowledges and assures that the County shall comply fully with the conditions
outfi6ed` in the ride WS County Grant Application .
Si nature Date :
Printed Name - _,, . W6sley S . Davis
.Position Title: .. , ;Chairman , Board of Coun Commissioners
}
3 . ContactPeftion . (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 : Brian S . Burkeen
Position Title : Assistant Chief
Address : 4225 43ru Avenue Vero Beach Florida 32966
Telephone : 772 226-3864 1 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
TOTAL Salaries NIA
TOTAL FICA NIA
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 category) ,
List the item and, if applicable, the quantity Amount
NIA
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
Cardiac Monitor Modems qty 19 $99900 .00
COhb Monitors qty 2 $9 ,000 . 00
HRG Responder Book qty 51 $4, 000 .00
Training Manikin $9 ,500 .00
TOTAL $329400. 00
GRAND TOTAL $329400 . 00
DH Form 1684 , Rev . June 2002
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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 2r Street Vero Beach Florida 32960
Federal Identification number VF 59-6000674 ti
Authorized Official :f,4: � r 79, 2
Signature Date
Wesley S. Davis. Chairman Board of County rd1mauissil6kers
Type Name and Title
10
Sign and return this page with your application to:
Florida Department of Health
BEMS Grant Program
4052 Bald Cypress Way, Bin C18
Tallahassee, Florida 32399- 1738
Do not write below this line. For use by Bureau of Emereencv Medical Services personnel only
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