HomeMy WebLinkAboutgrant applicationEMS COUNTY GRANT APPLICATION
FLORIDA DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services
Complete all items
L _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 corr ct. My signature acknowledges and assures that the County shall
comply fully with the condition out in the lorida EMS County Grant Application.
Signature: , '� ; . ' -: Date:.05./0
Printed Name:
Position Title:
1•=
Ge rge M. Burges
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 Mendelsberg
Position Title: Chief Financial Officer
Address: 9300 NW 41 Street
Miami, FL 33178
Telephone: (786) 331-5121
E-mail Address:
Fax Number: (786) 331-5137
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 —1 WORK PLAN FOR FY 2004-05 AND
ATTACHMENT — II EXPENDITURE PLAN FOR FY 2004-05 FOR DETAILS.
DH Form 1684, Rev. June 2002
1
BUDGET PAGE
A. Salaries and Benefits:
For each position title, provide the arnourit'of salary per hour, FICA per
hour, other fringe benefits, and the
total number of hours.
SEE ATTACHMENT — I WORK PLAN FOR FY 2004-05 AND
ATTACHMENT — II EXP, PLAN FOR FY 2004-05 FOR DETAILS.
TOTAL Salaries
TOTAL FICA
Grand total Salaries and FICA
Amount
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 applicabIe,•the quantity.
SEE ATTACHMENT — I WORK PLAN FOR FY 2004-05 AND
ATTACHMENT — II EXP. PLAN FOR FY 2004-05 FOR DETAILS.
TOTAL
Amount
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
Li of one (1) year or more.
item and,'if app1ic pief .'tf,`8 q . ntity i?�' u
SEE ATTACHMENT -- I WORK PLAN FOR FY 2004-05 AND
ATTACHMENT — II EXP. PLAN FOR FY 2004-05 FOR DETAILS.
DH Form 1684, Rev. June 2002
TOTAL
Grand Total
$1,300,305.28
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#59-600073
Authorized Official:
'(/
Signature
George M. Burges, County Manager
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
Date
Do not write below this line. For use by Bureau of Emergency Medical Services personnel only
Grant Amount For State To Pay: $ Grant ID: Code:
Approved By : Date
Signature of EMS Grant Officer
State Fiscal Year:
Organization Code:
64-25-60-00-000 N_
OCA
N2000
Obiect Code
7
Federal Tax ID: VF
Grant Beginning Date: October 1, Grant Ending Date: September 30,
DH Form 1767P, Rev. June 2002
3