Okaloosa County BOCC — November 15, 2016 — EMS County Grant Application 2016-2017 — reading text

County Government Application Form July 2016-2017 Effective August 26, 2016, county governments may submit their Fiscal Year 2016-2017 application for county grant funds. The deadline for submission is December 16, 2016. The new grant amount can be found in the “Total” column included in the link for the “county amount” table. The first three items on page one of the application are self-explanatory. Please note that Item 2 requires the signature of the individual who is authorized to sign contracts, grants, or other legal documents for the county. 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. If a previous one is still in-effect, a message from a lead county official stating such for 2016-2017 must be included. Item 5 requests the names of the organizations that will receive funds from the new county grant. A budget page is needed for each organization listed in item 5. The budget page must list 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 grant funds available. Changes may be requested after the new grant begins. To add budget totals in the application, 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 The Request for Grant Fund Distribution form is the last page of the application. The county is required to complete only the top portion of the form. In addition, the address on this form must be the same one that is on file in the state MyFloridaMarketplace (MFMP) system. If needed, MFMP customer service may be contacted at 1-866-352-3776, Monday to Friday, 8 a.m. to 6 p.m., or by email. MyFloridaMarketPlace@dms.myflorida.com.  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) C50____ 1. County Name: Okaloosa County Board of County Commissioners Business Address: c/o Office of Contracts & Grants 302 N. Wilson Street, Suite 203 Crestview, FL 32536-3474 Telephone: (850) 689-5000, 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: Charles K. Windes, Jr. 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 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: $28,476.00 DH 1684, December 2008 64J-1.015, F.A.C. 1 O 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 PPE for Tactical Combat Casualty Care: Ballistic Helmets $10,000.00 Ballistic Vests Level III $12,000.00 Tactical Communication Headsets $5,000.00 Tactical Medical Bags $1,476.00 Total Veh. & Equipment = $28,476.00 Grand Total = $28,476.00 DH 1684, December 2008 2  FLORIDA DEPARTMENT OF HEALTH EMERGENCY MEDICAL SERVICES (EMS) GRANT SECTION 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: The agency name and mailing address must be in the state MyFloridaMarketPlace (MFMP) system. 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 Charles K. Windes, Jr., Chairman Type or Print Name and Title Sign and return this page with your application to: Florida Department of Health Emergency Medical Services Section, 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: C50______ Approved By : Signature of State EMS Grant Officer Date State Fiscal Year: 2016 -__2017 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