Okaloosa County BOCC — July 7, 2015 — TD TE GRANT APPL SERVICE RATES FORM

Horldo Commission tor the Transportation Disadvantaged e esin Trip & Equipment Grant Application Form Disadvantaged Okaloosa County Board of County Commission 59-6000765-008 1804 Lewis Turner Boulevard, Ste 206 Fort Walton Beach, FL 32547 Janet Willis er | 850-609-7003 2d]| jwillis@co.okaloosa.fl.us 850-933-9286 7/1/2015 Okaloosa County Fiscal Year Budget Allocation Enter $ Amount Planning Funds Transferred from Planning Agency Grant Amount — State Allocation [90%)] $464,919 Grant Amount - Local Match [10%] 551,658 Voluntary Dollar Amount $30.00 Local Match for Voluntary Dollars [In Kind] $0.00 Total Project Amount | ~ $516,607.00 | Anticipated Capital Eqummflt Reque . . Enler $ Amount Enter Capital Equipment Description ] Enter $ Amount |_Enter Capital Equipment Description Enter $ Amount | Total Capital Equipment Request Amount | If Requesting Capital Equipment Local Coordinating Board Review IS Required This Application Form requesting the purchase of capital equipment has been review by the Enter Name of LCB Local Coordinating Board Enter Date Signature of Local Coordinating Board Chairperson Date I, Name of Grant Representative , as the authotized Grant Recipient Representative, hereby certify that the information contained in this form is frue and accurate and is submitted in accordance with the grant application_instructions. ’ gé\fJ 6/12/2015 Signgture of Grantkecnplent Representative Date Trip and Equipment Grant Application Form REVISED 20150611.docx Form Revised 6/11/2015 Horlda Commission for the % e g Transportation Disadvantaged Transportation Disadvantaged Trust Fund Service Rates Form TC) | Okaloosa County Board of County Commissioners {7/172015 . o Uhit'of Meastire 0 * Ambulatory ' Passenger Mile * Wheel Chair Passenger Mile * Stretcher Passenger Mile Bus Pass — Daily Pass Bus Pass — Weekly Pass Bus Pass — Monthly Pass Bus Pass — Monthly (Shuttle) Pass $15.00 Additional Service Transportation Mode Enter Unit of Measure Enter S Per Unit Additional Service Transportation Mode Enter Unit of Measure Enter S Per Unit Additional Service Transportation Mode Enter Unit of Measure Enter S Per Unit Additional Service Transportation Mode Enter Unit of Measure Enter S Per Unit Additional Service Transportation Mode Enter Unit of Measure. Enter S Per Unit Additional Service Transportation Mode Enter Unit of Measure Enter S Per Unit ‘Additional Service Transportation Mode Enter Unit of Measure Enter S Per Unit Additional Service Transportation Mode Enter Unit of Measure Enter § Per Unit Additional Service Transportation Mode Enter Unit of Measure Enter S Per Unit Additional Service Transportation Mode Enter Unit of Measure Enter S Per Unit Additional Service Transportation Mode Enter Unit of Measure Enter $ Per Unit Additional Service Transportation Mode Enter Unit of Measure Enter S Per Unit Additional Service Transportation Mode Enter Unit of Measure Enter S Per Unit Additional Service Transportation Mode Enter Unit of Measure Enter S Per Unit Additional Service Transportation Mode Enter Unit of Measure Enter S Per Unit Additional Service Transportation Mode Enter Unit of Measure Enter $ Per Unit * Ambulatory, Wheel Chair and Stretcher must all use the same Unit of Measure either Trip or Passenger Mile; Cannot mix, all must be the same regardless of Transportation Mode. Service Rates Form REVISED 20150611.docx Form Revised 6/11/2015