Backup Documents 09/13/2022 Item #16E6 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP L
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 1 U E 6
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office
at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later
than Monday preceding the Board meeting.
**NEW** ROUTING SLIP
Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the
exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office.
Route to Addressee(s) (List in routing order) Office Initials Date
2.
3. County Attorney Office County Attorney Office /
4. BCC Office Board of County
Commissioners L.ft 4n /
5. Minutes and Records Clerk of Court's Office
kr- 912212.24=4-4744,
PRIMARY CONTACT INFORMATION
Normally the primary contact is the person who created/prepared the Executive Summary. Primary contact information is needed in the event one of the addressees
above,may need to contact staff for additional or missing information. �►'f
Name of Primary Staff Cherie DuBock-. rGx'Y_nti Phone Number 239-252-3756
Contact/ Department
Agenda Date Item was 09/13/2022 Agenda Item Number -?3-1 U
Approved by the BCC Ig. E.6
Type of Document Grant Application&Resolution Number of Original 2
Attached Documents Attached
PO number or account
number if document is
to be recorded
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark"N/A"in the Not Applicable column,whichever is Yes N/A(Not
appropriate. (Initial) Applicable)
1. Does the document require the chairman's original signature? CD
2. Does the document need to be sent to another agency for additional signatures? If yes, CD
provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet.
3. Original document has been signed/initialed for legal sufficiency. (All documents to be CD
signed by the Chairman,with the exception of most letters,must be reviewed and signed
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's CD
Office and all other parties except the BCC Chairman and the Clerk to the Board
5. The Chairman's signature line date has been entered as the date of BCC approval of the CD
document or the final negotiated contract date whichever is applicable.
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's CD
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip CD
should be provided to the County Attorney Office at the time the item is input into SIRE.
Some documents are time sensitive and require forwarding to Tallahassee within a certain
time frame or the BCC's actions are nullified. Be aware of your deadlines!
8. The document was approved by the BCC on 9/13/2022(enter date)and all changes CD N/A is not
made during the meeting have been incorporated in the attached document. The an option for
County Attorney's Office has reviewed the changes,if applicable. this line.
9. Initials of attorney verifying that the attached document is the version approved by the N/A is not
BCC,all changes directed by the BCC have been made, and the document is ready for the an option for
Chairman's signature. this line.
I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 2.24.05;Revised 11/30/12
6E6
Ann P. Jennejohn
From: Ann P.Jennejohn
Sent: Thursday, September 22, 2022 10:07 AM
To: DuBockCheri
Subject: Resolution 2022-134 &Grant Application
Attachments: Resolution 2022-134 &Grant Application.pdf
Good Morning Cheri,
Please see the attached for further processing.
After obtaining Kecessary sigvtature(s), please
return a Fully executed copy to this office for the
records of the Board of County Commissioners.
Thank you!
Ann Jennejohn
BMR Senior Deputy Clerk II
°\t,iH k, Clerk to the Value Adjustvvtent Board
Office: 2367-252-840(0
Fax: 239-252-8408 (if applicable)
Ann.Jennejohn@CollierClerk.com
.�e Office of the Clerk of the Circuit Court
Sr Comptroller of Collier County
32q Tamiami Trail, Suite *401
Naples, FL 34112-5324
www.CollierClerk.covv'
i
16E6
RESOLUTION NO. 2022- 1 3 4
A RESOLUTION OF THE BOARD OF COUNTY COMMISSIONERS OF
COLLIER COUNTY, FLORIDA, CERTIFYING THAT THE
APPLICATION FOR AND USE OF EMS COUNTY GRANT FUNDS
WILL IMPROVE AND EXPAND PRE-HOSPITAL EMS DEPARTMENT
ACTIVITIES AND WILL NOT SUPPLANT EXISTING COUNTY EMS
BUDGET ALLOCATIONS.
WHEREAS, EMS Department Paramedics and Paramedic/Firefighters provide basic and
advanced life support care and highly technical service to the citizens and visitors of Collier
County; and
WHEREAS,the purchase of equipment and provision of training shall greatly enhance the
effectiveness of pre-hospital emergency medical care.
NOW, THEREFORE, IT RESOLVED BY THE BOARD OF COUNTY
COMMISSIONERS OF COLLIER COUNTY, FLORIDA. that:
The $72,756.00 in the EMS County Grant will be used to provide training and purchase
medical/rescue equipment and these funds will not be used to supplant existing EMS Department
budget allocations.
THIS RESOLUTION PASSED AND DULY ADOPTED by the Board of County
Commissioners of Collier County, Florida, this 13`h day of September 2022.
,`-\,'iATTEST: BOARD OF COUN Y COMMISSIONERS
,�p..•'i RYSTAI;°IS KINZEL, CLERK COLLIER CO - • * I •
: -fit ' *"„.' ': - . ..":c4 Ce) , 0 '
It A By. �l , Air►
F^ '1 Will,.m
-
c - Clerk l,. L. McDaniel, Jr., Chain an
� la' . n s
4 • ,signatdre only,
Appr. v ,,., • "rm and legality:
pia
III SOB.•
Jeffre T. . KI kow, County Attorney
1
EMS COUNTY GRANT APPLICATION 2022- 2023
FLORIDA DEPARTMENT OF HEALTH
Emergency Medical Services Program
` 3.. �P,11 Complete all items
s r-
ID. Code(The State EMS Program will assign the ID Code— leave this blank)
1. County Name: Collier
Business Address: 3299 Tamiami Trail East, Suite 700
Naples, FL 34112-5747
Telephone: 239-252-3740
Federal Tax ID Number(Nine Digit Number): VF 59-6000558
2. Certification: (The applicant s - .. ho has authority to sign contracts, grants, and other legal
documents for the county) I ce •' 0".t all in o -.tion a • data in this EMS county grant application and
its attachments are tr a c, — signature :c owle,• :nd assures that the county shall
comply fully with the o • ou J c0 t - Fl. id. ,1!• • y Grant Application.
Signature: _�r` v Date: cf//,3/2Z
Printed Name: , liam McDaniel
Position Title: 1hairman
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: Cherie DuBock
Position Title: Accounting Supervisor
Address: 8075 Lely Cultural Parkway, Suite 267
Naples, FL 34113
Telephone: 239-252-3756 Fax Number: 239-252-3298
E-mail Address: cherie.dubock@colliercountyfl.gov
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 this resolution.
5. Organization List: Complete a budget page(s) for each organization, which at your option you will
provide funds. List the organization(s) below. (Use additional pages if necessary)
Collier County Emergency Medical Services
A TEST"'
CRYSt#41C KINal,CLERK
BY I.-- ., - ., °_ •
� �. ,6h.q ; ''-S
s1 nature nn y.
DH 1684, December 2008 (Rev.July 2018) 64J-1.015, F.J.C.
1
((A(7ri
1 6E
BUDGET PAGE -When the budget form is in your computer, the budget totals below should be
added for you if you place your cursor over a subtotal or total field, right click your mouse, then left
click "Update Field" on the resulting menu.
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
Medical/Rescue Equipment $72,756.00
Total Vehicles & Equipment= $ 0.00
Grand Total = $ 72,756.00
DH 1684, December 2008
2
;ICAO?
ey, '
FLORIDA DEPARTMENT OF HEALTH
EMERGENCY MEDICAL SERVICES(EMS) GRANT UNIT
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 county name, address, and corresponding federal ID number used herein must be in the state
MyFloridaMarketPlace (MFMP) system. A finance person in your organization who does business with the
state can provide these.
Name of County: Collier County Board of County Commissioners
Mailing Address: 3299 Tarniami Trail East. Suite 700
Naples, FL 34112-5747
Federal 9-digit Identification n : •9-,00 58 ,di•it seq. code
y ��. - ,- • ��I/ Z
Authorized Count Official: C `�
Sig :ture Date
William McDaniel, Chairman
Type or Print Name and Title
Sign and return this page with your application to: ATTEST
Appro , ertorm and legality. Florida Department of Health CRYSTAL K.KINZEL,CLBRK
Emergency Medical Services Unit, Grants , OC
Jeffrey A.Klatzkow $}(;� ',,
County A orney 4052 Bald Cypress Way, Bin A-22 •
Tallahassee, Florida 32399-1722 {::� �S tt) Rlla— hre
Do not write below this line. For use by State Emergency Medical St vc'st Sec Ion
Grant Amount for State to Pay: $ Grant ID: Code: ��•' .
atsi��
Approved By:
Signature of State EMS Unit Supervisor Date
Approved By:
Signature of Contract Manager Date
State Fiscal Year: 2022 - 2023
Organization Code E.O. OCA Object Code Category
64-61-70-30-000 05 SF005 751000 059998
Federal Tax ID:VF _ Seq. Code:
Grant Beginning Date: Grant Ending Date:
DH 1767P, December 2008(rev.June 8,2018), incorporated by reference in F.A.C. 64J-1.015.
3