HomeMy WebLinkAbout2005-035 GRANT APPLICATION
FLORIDA DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services
Com lett all items
M The State Bureau of EMS will assign the ID Code - leave this blank C
1 . County Name: Indian River County
Business Address: 1840 25m Street Vero Beach Florida 32960
Telephone : 772 5674154
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 t Flo ' a EMS County Grant Application .
t
Signature : Date : January 18 , 2005
Printed Name : Thomas S. Lowther
Position Title: Chairman, Board of CountCommissioners
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: EMS Chief
Address: 1840 2V Street Vero Beach Florida 32960
Tele hone: 772 5624028 X 3015 Fax Number: 772 770=5147
E-mail Address : bburkeen@lrcgov.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 count 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 Department of Emergency Services
DH Form 1684, Rev, June 2002
BUDGET PAGE
A . Salaries and Benefits :
For each position title, provide the amount of salary per hour, FICA
fringe benefits, and the total number of hours. Per hour, other
Amount
[TOTAL
OTAL Salaries NIA
FICA NIA
Grand total Salaries and FICA NIA
Be 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
ex enditures classed as operating capital outlay see next category) ,
List the item and if a licable the uanti Amount
Mobile Data Terminal License 23 Units X17,250.00
Airtime Service for One Year 23 Units) 5161560.00
TOTAL 533,810.00
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
Laptop Computers 18 Units $27000000
Air Cards 18 Units $7,650.00
Vehicle Mounts 18 Units $6,840.00
TOTAL $41 ,490.00
GRAND TOTAL $75,300.00
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 : 1840 2e Street Vero Beach Florida 32960
Federal Identification number VF 59-6000674
Authorized Official : 5 ( t�.� 01 - 18 - 2005
Signature Date
Thomas S. Lowther. 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 C 18
Tallahassee, Florida 32399. 1738
Do not write bdow this- Him For ate b Bu of Ememency Medkxl Services Demnimel only
Grant Amount For State To Pay: $ Grant ID: Code:
Approved By :
Signature of EMS Grant Officer Date
State Fiscal Year:
Organization Code E. 0, OCA Object Codd
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