HomeMy WebLinkAboutEMS County Grant ApplicationEMS COUNTY GRANT APPLICATION
FLORIDA DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services
Complete all items
ID. Code The State Bureau of EMS will assign the ID Code — leave this blank C
1. County Name: MIAMI-DADE COUNTY
Business Address: 111 NW 1 Street, Floor 29
Miami, FL 33128
Telephone: 305 375-5311
Federal Tax ID Number Nine Digit Number). VF #59-6000573
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 condit�utlined the Florida EMS County Grant Application.
Si nature:��� __ Date: 1,7 1
Printed Name: Geor a M. Burgess
Position Title: County Manager
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: Scott Mendeisber
Position Title: Assistant Director
Address: 9300 NW 41 Street
Doral, FL 33178
Telephone: 786 331-5121 Fax Number: 786 331-5123
E-mail Address:
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)
SEE ATTACHMENT — I WORK PLAN FOR FY 2008-09 AND
ATTACHMENT — II EXPENDITURE PLAN FOR FY 2008-09 FOR DETAILS.
DN Form 1684, Rev. June 2002
00OGBPAGE
A- Saa,iesmnmsmnmntm-
pro hour, FICA
For ea s n tie, vide the amount
s 9f salary P'e
positio
'.benefits rid 9.9 rn o
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SEE ATTACHMENT — I WORK PLAN FOR FY 2008-09 AND
ATTACHMENT — 11 EXP. PLAN FOR FY 2008-09 FOR DETAILS.
ATTACHMENT — If EXP. PLAN FOR FY 2007-08 FOR DETAILS.
TOTAL Salaries
TOTAL FICA
$
B. Expenses: These are travel costs and the usual, ordinary, and incidental expenditures bynn
agency, such as, commodities and supplies ofaconsumable nature excluding expenditures douoifiodas
nmoraUnooaoKa/ouUav(see next oabemo
:List the item and, if app th- uiim
SEE ATTACHMENT — I WORK PLAN FOR FY 2008-09 AND
ATTACHMENT — If EXP- PLAN FOR FY 2008-09 FOR DETAILS.
TOTAL $
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
ty
SEE ATTACHMENT— I'VVORK PLAN FOR FY 2007-08 AND
ATTACHMENT — If EXP. PLAN FOR FY 2007-08 FOR DETAILS.
TOTAL
$
Grand Total
$1,263,324.75
DH Form 1684, Rev. June 2002
2
FLORIDA 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: MIAMI-DADE COUNTY BOARD OF COUNTY COMMISSIONERS
Mailing Address: 111 NW 1 STREET, FLOOR 26 (FINANCE DEPT)
MIAMI FLORIDA 33128
Federal Identification number#59-6000573
Authorized Official:
Signature Oate
George M. Burgess, County Manager
Type Name and Title
Sign and return this page with your application to.
Florida Department of Health
GEMS Grant Program
4052 Bald Cypress Way, Bin C18
Tallahassee, Florida 32399-9738
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: 2007 -2008
Organization Code E.O.. OCA
64-42-10-00-000 05 SF005
Federal Tax ID: VF
Grant ID: Code: C70
Object Code
750000
Date
Grant Beginning Date: October 1, 2007 Grant Ending Date: September 30, 2008
DH Form 1767P, Rev. June 2002