HomeMy WebLinkAboutFund DistributionFLORIDA 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 nutnber#59-6000573
Authorized Official:
Signature
George M. Burgess, 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
Do not write below this line. For use by Bureau of Emergency Medical Services personnel only
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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, _
Dl-1 Form 1767P, Rev. June 2002
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