HomeMy WebLinkAbout2008-022DEPARTMENT OF HEALTH
EMS GRANT PROGRAM
I
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
Authorized 11 '
Signature Date
Sandra L. Bowden, Chairman Board of County Commissioners
Type Name and Title
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 Emergency Medical Services personnel only
Grant Amount For State To Pay: $
Approved By:
Signature of EMS Grant Officer
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,
DH Form 1767P, Rev. June 2002
Grant ID: Code:
Date
Grant Ending Date: September 30,
FLORIDA DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services
Complete all items
he State Bureau of EMS will assign the ID Code — leave this blank
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 EMS County Grant Application.
Signature: Date:
Printed Name: Sandra L. Bowden
Position Title: Chairman, Board of County Commissioners
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: Brian S. Burkeen
Position Title: Assistant Chief
Address: 4225 43r Avenue Vero Beach Florida 32966
Telephone: (772) 226-3900 X 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 N
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
EZ 1/0 Drill qty 15
$221500.00
COM Monitors qty 2
$83000.00
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 outlav (see next cateaorv)_
List the item and, if applicable, the quantity
Amount
EZ 1/0 Drill qty 15
$221500.00
COM Monitors qty 2
$83000.00
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) vear or more.
List the item and, if applicable, the quantity
Amount
EZ 1/0 Drill qty 15
$221500.00
COM Monitors qty 2
$83000.00
TOTAL
$307500.00
GRAND TOTAL
$301500.00
DH Form 1684, Rev. June 2002