Resolution 2003-458
1601
RESOLUTION NO. 200 3- A..5..lL-
A RESOLUTION CERTYFING THAT THE APPLICATION FOR AND THE USE
OF EMS COUNTY GRANT FUNDS WILL IMPROVE AND EXPAND PRE-
HOSPITAL EMS DEPARTMENT ACTIVTIES AND SERVICES AND WILL
NOT SUPPLANT EXISTING COUNTY EMS BUDGET ALLOCATIONS.
WHEREAS, EMS Department Paramedics and ParamediclFirefighters provide
basic and advanced life support care and highly technical service to tJ~e citizens and
visitors of Collier County; and
WHEREAS, the purchase of equipment and the provision of training classes 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 $142,168.03 in the EMS Grant will be used to purchase medical/rescuer
equipment and training classes and these funds will not be used to supplant existing EMS
Department budget allocations.
This)~c;~olution adopted this tit,"fh day of ~...rY\~r
J,,~l~ . ~'.':'~l.l:.:' ~ '.
motiqil,secoqd. a~~ majority vote.
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AttEST: . "Ij.'\'~',1.:~.
DWI~JfI:.E. BRQC'K,,~LERK
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bzj~t~k~t 0.<:. BY
If gnaturt Of! , 1.
, 2003 after
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EMS COUNTY GRANT ApPLlCA TION
FLORIDA DEPARTMENT OF HEAL TH
Bureau of Emergency Medical Services
16[JJ
Complete all Items
10. Code (The State Bureau of EMS will assign the 10 Code - leave this blank) C
S
2. Certification: (The applicant signatory who has authority to sign contracts, grants, and other legal
documents for the county) I certify, at all inf ration and data in this EMS county grant application and
its attachments are true and co ct. My s' ture acknolQlledges and assures that the County shall
comply fully with the conditions u lined i Flor' a EMS County Grant Application.
Si nature: Date:
Printed Name:
Position Title:
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: . 1
Position Title:Fiscal Tech.
Address: 3301 Tamiarni Trail East Build~n H
Na les FL 34112
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.
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)
Collier County EMS
DH Form 1684, Rev. June 2002
Approved as to form & legal sufficiency
3
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.
Amoun
1
TOTAL Salaries
TOTAL FICA
Grand total Salaries and FICA
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 excludino expenditures classified as
oDeratinQ capital outlay (see next cateQorv).
List the Item and, If applicable, the quantity Amount
". - . _. "~ ".-.- .'.- ..-. .. ..". .- .~ '-l"_.'"''''' '~,",__.':,_'-'L..". _.._ _ ''___ ~ . -. ... .__w '-- ~ "...... " . --,_. .-.--...-. .....- _.'_W"' 0___.___
..
TOTAL $
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.
Llat the item and, If applicable, the quantity Amount
M""r'l; ,.."', /Q Eauinment S100 000 00
Trainina $ 42,168.03
TOTAL $
.- 142,168.03
Grand Total $ 142,168.03
DH Form 1684, Rev. June 2002
4
FLORIDA DEPARTMENT OF HEAL TH
EMS GRANT PROGRAM
REQUEST FOR GRANT FUND DISTRIBUTION
In accordance with the provisions of Section 401.113(2)(a), F. S., 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: COLLIER COUNTY BOARD OF COMMISSIONERS
Mailing Address: 3301 East Tamiami Trail
Federal Identification number
Date
Authorized Official:
Tom Henning, Chairman
Type Name and Title
Sign and return this page with your application to:
Florida Department of Health
BEMS Grant Program
4052 Bald Cypress Way, Bin C18
Tallahassee, Florida 32399-1738
Do not write below this line. For use by Bureau of Emergency Medical Services personnel only
Grant Amount For State To Pay: $
Grant 10: Code:
Approved By :
Signature of EMS Grant Officer
Date
State Fiscal Year:
Oraanization Code
64-25-60-00-000
J;,Q,
N
OCA
N2000
Obiect Code
7
Federal Tax 10:
VF.5.9.6.QD.Q 5.5JL_
Grant Beginning Date: October 1,
Grant Ending Date: September 30,
DH Form 1767P, Rev. June 2002
5