Okaloosa County BOCC — December 1, 2015 — EMS County Grant Application 2015-2016 — reading text

Application Form July 2015-2016 Effective July 24 County Governments may submit their Fiscal Year 2015-2016 application for county grant funds. The deadline for state EMS to receive the required pages of your completed county grant application form is by December 16, 2015. You can see the amount of your new grant at the state EMS website in the “Total” column of the county amount table. The first application form page has five items, the first three of which are self-explanatory. However, note that Item 2 is where the county's authorized person must provide his/her signature. Item 4 describes the content of the resolution. Please provide this in your county’s customary format and approval process. The resolution must be current and not a copy of a previous resolution. We need this current resolution or we will not be able to process the application for funds. Item 5 of the first page of the application form asks for the name of the organizations that will receive funds from your new county grant. The second page of the application form is the budget page and one of these budget pages is needed for each organization listed in item 5, The budget page for each organization must have on it specific and quantifiable items or services, with the cost for each unit or type of item or service. All costs must add to the exact amount of new funds for your grant. You can transfer unexpended funds from your previous grant after the new grant begins. No general statements can be used in the budget because we are now required to have specificity up-front and need it to obtain your grant funds. However, you can still make change requests during the new grant, so you do not lock yourself into the initial items. Your budget totals in the application should be added for you if you place your cursor over a subtotal or total field, right click your mouse, then left click on the resulting menu “Update Field.” Request for Grant Fund Distribution Form This page is included with your application form. Complete only the top part of this form and the state will complete the bottom part, as indicated on the form. .  EMS COUNTY GRANT APPLICATION FLORIDA DEPARTMENT OF HEALTH Emergency Medical Services Program Complete all items ID. Code (The State EMS Program will assign the ID Code – leave this blank) C40____ 1. County Name: Okaloosa County Board of County Commissioners Business Address: c/o Office of Contracts & Grants 101 E. James Lee Boulevard, Room #104 Crestview, FL 32536 Telephone: (850) 651-7200, Ext. 4381 Federal Tax ID Number (Nine Digit Number). VF 59-6000765 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: Nathan D. Boyles Position Title: Chairman, Okaloosa County Board of County Commissioners 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: Tracey D. Vause Position Title: Okaloosa County EMS Chief Address: 90 College Boulevard East Niceville, FL 32578 Telephone: (850) 651-7150 Fax Number: (850) 651-7170 E-mail Address: tvause@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. We cannot process for funds without a current resolution. 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) Okaloosa County EMS: $31,206.00 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 = $ 0.00 TOTAL FICA & Other Benefits = Total Salaries & Benefits = $ 0.00 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 Expenses = $ 0.00 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 Honda ATV $6,800.00 AED x 10 $10,000.00 EMS Training Equipment $10,000.00 Vivid Trac Airway Cameras $4,406.00 0 Total Veh. & Equipment = $31,206.00 Grand Total = $31,206.00 DH 1684, December 2008 2  FLORIDA DEPARTMENT OF HEALTH EMERGENCY MEDICAL SERVICES (EMS) GRANT PROGRAM REQUEST FOR GRANT FUND DISTRIBUTION In accordance with the provisions of Section 401.113(2) (a), Florida Statutes, 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 N. Wilson Street, Suite 203 Crestview, FL 32536 Federal Identification number: 59-6000765 Authorized County Official: Signature Date Nathan D. Boyles, Chairman Type or Print Name and Title Sign and return this page with your application to: Florida Department of Health Emergency Medical Services Program, Grants 4052 Bald Cypress Way, Bin A-22 Tallahassee, Florida 32399-1722 Do not write below this line. For use by State Emergency Medical Services Program Grant Amount For State To Pay: $__________________ Grant ID: Code: C40______ Approved By : Signature of State EMS Grant Officer Date State Fiscal Year: 2015 -__2016 Organization Code E.O. OCA Object Code Category 64-61-70-30-000 05 SF005 750000 059998 Federal Tax ID: VF __ __ __ __ __ __ __ __ __ Grant Beginning Date: ____________________ Grant Ending Date: _______________ DH 1767P, December 2008 64J-1.015, F.A.C. 3