Okaloosa County BOCC — October 5, 2013 — EMS Grant Application 2013-2014 — reading text

EMS 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: Okaloosa County Board of County Commissioners Business Address: c/o Office of Contracts & Grants 1904 Lewis Turner Boulevard, Suite 206 Fort Walton Beach, FL 32547 Telephone: (850) 651-7200, ext 4381 Federal Tax ID Number (Nine Digit Number). VF__ 5 __ 9 -__ 6 __ 0 __ 0 __ 0 __ 7 __ 6 __ 5 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 the Florida EMS County Grant Application. Signature: Date: Printed Name: Don R. Amunds Position Title: Chairman 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: Dino J. Villani Position Title: Director, Okaloosa County Department of Public Safety Address: 90 College Boulevard East Niceville, FL 32578 Telephone: (850) 651-7150 Fax Number: (850) 651-7170 E-mail Address: dvillani@co.okaloosa.fl.us 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) 1. Okaloosa County Public Safety - $28,425.00 DH 1684, December 2008 64J-1.015, F.A.C. 1 BUDGET PAGE A. Salaries and Benefits: For each position title, provide the amount of salary per hour, FICA per hour, other fringe benefits, and the total number of hours. Amount TOTAL Salaries TOTAL FICA Grand total Salaries and FICA 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 applicable, the quantity Amount 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 of one (1) year or more. List the item and, if applicable, the quantity Amount Rescue Boards (5 @ $1,058.60 each) $ 5,293.00 King Vision Video Laryngoscope (14 @ $1,398.00 each) $19,572.00 CPAP Machine (3 @ $1,000.00 each) $ 3,000.00 Temporal Thermometers (14 @ $40.00) $ 560.00 TOTAL $ 28,425.00 Grand Total 28,425.00 $__________ DH1684, December 2008 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: Okaloosa County Board of County Commissioners Mailing Address: 302 Wilson Street, Suite 203 ________ Crestview, FL 32536 ______ 59-6000765 Federal Identification number ______________________________________ Authorized Official: Signature Date Don R. Amunds, Chairman 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 A22 Tallahassee, Florida 32399-1722 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 : Signature of EMS Grant Officer Date State Fiscal Year: - Organization Code E.O. OCA Object Code 64-42-10-00-000 750000 Federal Tax ID: VF _ _ _ _ _ _ _ _ _ Grant Beginning Date: __________________ Grant Ending Date: _________________ DH 1767P, December 2008 64J-1.015, F.A.C. 5