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Backup Documents 10/09/2018 Item #16E 5 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 1 b E 5 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 routinglines#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. 2. 3. County Attorney Office County Attorney Office itC:tA 1t) 1 l' 1 4. BCC Office Board of County -AS Commissioners ,.� ) 16&11'1 5. Minutes and Records Clerk of Court's Office y ku lO(te ( 31S PRIMARY CONTACT INFORMATION I 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 Artie Bay Phone Number 252-3756 Contact/ Department Agenda Date Item was 10/9/18 Agenda Item Number 16E 5 Approved by the BCC Type of Document Resolution and Grant Application Number of Original 1 Attached Documents Attached PO number or account 24`g—)'1 I . number if document is to be recorded INSTRUCTIONS & CHECKLIST Initial the Yes column or mark"N/A"in the Not Applicable column,wh3.cheveris � Yes N/A(Not appropriate. !/ (Initial) Applicable) 1. Does the document require the chairman's original signature? S 6 n/a 2. Does the document need to be sent to another agency for additio 1 signatures? , n/a 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 signed by the Chairman,with the exception of most letters,must be reviewed and signed ab by the Office of the County Attorney. 4. All handwritten strike-through and revisions have been initialed by the County Attorney's n'a 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 ab 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 ab signature and initials are required. 7. In most cases(some contracts are an exception),the original document and this routing slip n/a 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 10/9/18 (enter date)and all sae c. changes made during the meeting have been incorporated in the attached document. .3W) _ ,„ The County Attorney's Office has reviewed the changes,if applicable. Via 9. Initials of attorney verifying that the attached document is the version approved by the K' 941i=, BCC,all changes directed by the BCC have been made,and the document is ready for the : a „ Chairman's signature. ,k..,. I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 2.24.05;Revised 11/30/1294--N- 16E5 RESOLUTION NO. 2018 - 1 71 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, BE IT RESOLVED BY THE BOARD OF COUNTY COMMISSIONERS OF COLLIER COUNTY, FLORIDA, that: The $63,545.00 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 ADOPTED after motion, second, and majority vote favoring same this h day of O ,1+©h pf' , 2018. ATTEST: , BOARD OF COUNTY COMMISSIONERS, CHRYS T` I :I L1~.T , CLERK COLLIER CO Y, FLORIDA 6-11 BY: racy BY: Deputy 1 ANDY SOLIS, CHAIRMAN Attest as to Chairman s signature only. Approved as to form and legality: �' Jenn er A. Belpedi 0Y, Assistant County Attorney o\\ 16E 5 EMS COUNTY GRANT APPLICATION FLORIDA DEPARTMENT OF HEALTH F'or_da Emergency Medical Services Program HEALTH Complete all items ID. Code (The State EMS Program will assign the ID Code—leave this blank) C70 1. County Name: Collier Business Address: 3299 Tamiami Trail East, Suite 700 Naples, FL 34112-5747 Telephone: 239-2 52-3740 Federal Tax ID Number(Nine Digit Number): VF 59-6000558 3 digit code: 007 2. Certification: (The appli nt si tory who . • ty to sign contracts, grants, and other legal documents for the county certi atll infori - .n : data in this EMS county grant application and its attachments are true nd c ct. My sign- . e - powledges and assures that the county shall comply fully with the c iti o in d in -- • • MS County Grant Application. Signature: ,•' Date: (O i 7 )iR Printed Name: Andy Solis 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: Artie Bay Position Title: Supervisor—EMS Admin. Address: 8075 Lely Cultural Pkwy, Naples, FL 34113 Telephone: 239-252-3756 Fax Number: 239-252-3298 E-mail Address: Artie.Bay@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 DH 1684, December 2008(Rev.July,2018) 64J-1.015, F.A.C. 1 ATTEST: Approved as to form and legality Y T 1NZEL, CLERK sistant Cou • Deputy lert Mt t as to Chairman's o`\`�' n1 signature only. � 16E 5 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 Training 5,000 Tuition for Paramedic School 50,000 • • Total Expenses= $ 55,000.00 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 8,545 Total Vehicles & Equipment= $ 8,5450.00 Grand Total= $ 63,545.00 DH 1684, December 2008 2 1 6 E 5 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 agency name, address, and federal ID number must be in the state MyFloridaMarketPlace (MFMP) system. Ask a finance person in your organization who does business with the state to provide these. Name of Agency: Collier County Board of County Commissioners Mailing Address: 3299 Tamiami Trail East,Suite 700 Naples, FL 34112-5747 Federal 9-digit Identification numbe . 59-6 558 3-digit seq. code Authorized County Official: Signature Date Andy Solis, Chairman Type or Print Name and Title Approved as to form and Irgal►tY Sign and return this page with your application to: Florida Department of Health ATTEST: RYST• KI ZEL, CLE- ')-) ... ')j Emergency Medical Services Unit, Grants --` Assistant County LY �$ 4052 Bald Cypress Way, Bin A-22 ► ��� R.\ ' Tallahassee, Florida 32399-1722 St as to O ';r'j pu 1 sigqnature only Do not write below this line. For use by State Emergency Medical Services Section Grant Amount for State to Pay: $ Grant ID: Code: C70 Approved By: Signature of State EMS Unit Supervisor Date Approved By: Signature of Contract Manager Date State Fiscal Year: 2018 - 2019 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