Backup Documents 11/14/2023 Item #16F 5 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO
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
1. County Attorney Office County Attorney Office
2. BCC Office Board of County.
Commissioners Rt.1 /r/31c( I(/I7/Z3
3. Minutes and Records Clerk of Court's Office 3,0
4.
5.
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.
Name of Primary Staff Cherie DuBock/EMS Phone Number 239-252-3756
Contact/ Department
Agenda Date Item was 11/14/2023 Agenda Item Number 27022
Approved by the BCC I C F 5
Type of Document EMS 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
si attire 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 11/14/2023 (enter date)and all CD N/A is not
changes made during the meeting have been incorporated in the attached document. an option for
The 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 •6S N/A is not
BCC,all changes directed by the BCC have been made, and the document is ready for the n an option for
Chairman's signature. 1 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
Instructions: County Government Application Form 2023-2024
The first application page has five numbered items.
Please note that 'tern 2 on the first application page is where the county's authorized person must
provide his/her signature and the date.
Item 4 describes the content of the current"resolution" that is required. However, if a previous
resolution has continuing authority, include a signed message about this and provide a copy of the
previous resolution.
Item 5 of the first page of the application form asks for the name of the organization(s)to which you
decide to allocate 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 county alone has the authority to use all the grant funds itself or to provide some of the funds to
other organizations within the county. However, the county remains responsible to the state for all
the funds.
The budget costs must total to the exact amount of new funds for your grant. You can request
budget changes and to add to the new grant budget unexpended previous funds from the prior grant,
after the new grant begins.
The Request for Grant Fund Distribution Form is the last page herein and you must complete only
the top part of the form. State EMS will complete the bottom part, as stated on the form.
You should copy all forms on your computer to use them. If you place them in restricted editing
mode, you can use your keyboard Tab key to go from field to field.
Note:This instruction form is for information purposes only and is not part of form DH 1684.
[23-EMS-01182/1821770/1] �O
V
EMS COUNTY GRANT APPLICATION
•" "'"� FLORIDA DEPARTMENT OF HEALTH
Emergency Medical Services Program
HEALTH Complete all items
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 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.
BOARD OF COUNTY COMMISSIONERS ATTEST: Dated: 1 f/W/21
COLLIER-COUN Y,F ORIDA Crystal K.Kinzel,Clerk t
_ By: BY Li '' t
Rick LoCastro,Chairman - i tp lairmatt,.
3.Contact Person: (The individual with direct knowledge of the projv ;i ;ul'(144day 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 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.
SEE EXHIBIT "A" attached hereto and incorporated by reference herein.
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
Approved as to Form and Legality:
V)-4
OP rb
Dere D. Perry ry0
Assistant County Attorney o\t\i)
DH 1684, December 2008(Rev. July 2018) 64J-1.015, F.A.C.
1
[23-EMS-01182/1821770/1] 0
Ci
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 $78,658.02
Total Vehicles & Equipment= $ 0.00
Grand Total= $78,658.02
DH 1684, December 2008
2
[23-EMS-01 1 82/1 821 770/1] P►0
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 Tamiami Trail East, Suite 700
Naples, FL 34112-5747
Federal 9-digit Identification numb/et. 000558 3-digit seq. code
Authorized County Official: J �I �I y123
Signature Date
Attest: -
CRYSTAL K. KINZEL; CLERK Rick LoCastro, Chairman App ed as to Form and Legality:
Type or Print Name and Title
tAlir \Or
)1-1 t4"--tt. z Sign and return this page with your application to. Derek D.Perry
hest a10 'dads Assistant County Attorney n\N�
Only. Florida Department of Health N
Emergency Medical Services Unit, 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 Section
Grant Amount for State to Pay: $ Grant ID: Code:
_Approved By:
Signature of State EMS Unit Supervisor Date
Approved By:
Signature of Contract Manager Date
State Fiscal Year: 2023 - 2024
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
[23-EMS-01182/1821770/1] CiQ►O
Exhibit "A"
Board Resolution
RESOLUTION NO. 2023-2 0 6A
A RESOLUTION OF THE BOARD OF COUNTY
COMMISSIONERS OF COLLIER COUNTY, FLORIDA,
CERTIFYING THAT THE APPLICATION FOR AND USE
OF EMERGENCY MEDICAL SERVICES (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 $78,658.02 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 /9 ryday of NO VEM6'ElZ 2023.
ATTEST: BOARD OF COUNTY COMMISSIONERS
CRYSTAL K..KINZEL, CLERK COLLIER COUNTY, FLORIDA
By: n `" ' `f�l ��- By:
Attestiatotcloinan Rick LoCastro, Chan man
signature only.
Approy d as to form and legality:
Dere D. Perry
Assistant County Attorney ,\tO`
[23-EMS-01182/1822709/1] Page 1 of 1 �0