HomeMy WebLinkAboutDocumentation_Regular_Tab 03_04/11/2013 VILLAGE OF TEQUESTA
AGENDA ITEM TRANSMITTAL FORM
1. VILLAGE COUNCIL MEETING:
Meeting Date: Meeting Type: Regular Ordinance #: Click here to enter text.
April 11, 2012
Consent Agenda: Yes Resolution #: Ctick here to enter text.
Originating Department: Manager
2. AGENDA ITEM TITLE: (Wording form the SUBJECT line of your staff report)
1. Per Village Ordinance we are presenting the following agreements, proposals, commitments and
memorandum of understanding to Council:
3. BUDGET / FINANCIAL IMPACT:
Account #: Click here to enter text. Amount of this item: Click here to enter text.
Current Budgeted Amount Available: Amount Remaining after item:
Click here to enter text.
Budget Transfer Required: No Appropriate Fund Balance: No
4. EXECUTIVE SUMMARY OF MA�JOR ISSUES: (This is a snap shot description of the agenda item)
1. Per Village Ordinance we are presenting the following agreements, proposals,
commitments and memorandum of understanding to Council:
a. Florida Department of Health, EMS Matching Grant Application with the Village of
Tequesta.
b. Dailey and Associates, Inc. and the Village of Tequesta proposal for services related to
Annexation Areas "C" and Sandpoint Bay Condominium
5. APPROVALS:
Dept. Head: Finance Director: ❑ Reviewed for Financial
Sufficiency
� No Financial Impact
Attorney: (for legal sufficiency) Yes ❑ No ❑
Village Manager:
• SUBMIT FOR COUNCIL DISCUSSION: �
• APPROVEITEM: ❑
• DENY ITEM: �
�
MEMORANDUM
�� .
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- Village of Tequesta
Administration
TO: Village Council
FROM: Michael Couzzo, Village Manager
DATE: April 11, 2013
SUBJECT: Presentation of Agreement, Contracts, etc.
Per Village Ordinance I respectfully present the following agreements, proposal,
commitments and memorandum of understanding to Council.
a. Florida Department of Health, EMS Matching Grant Application with the Village of
Tequesta.
b. Dailey and Associates, Inc. and the Village of Tequesta proposal for services
related to Annexation Areas "C" and Sandpoint Bay Condominium.
VILLAGE OF TEQUESTA
MEMORANDUM VILLAGE CLER�S OFFICE
TO: Michael Couzzo, Village Manager
CC: Nilsa Zacarias, Community Development Director
Keith Davis, Villa.ge Attomey
FROM: Lori McWilliams, Village Clerk
DATE: March 22, 2013
SUBJECT: Metes and Bounds — Annezation Special Flection
The attached agreement authorizes Daily and Associates to begin preparing the required
metes and bounds for proper advertisement prior to the Village's August 27, 2013 Special
Anne�ation Election.
Costs broken down are as follows:
Area C $1500
Sandpointe Bay �
�1900
Please authorize payment in oxdex for Dailey and Associates to be�n work.
DAILEY AND ASSOCIATES, INC.
surveying and mapping
� 112 North US Highway One
Tequesta, Florida 33469
561.746.8424
fax 561.746.8575
new e-mail dailey.office@att.net
March 22, 2013
Attn: Niisa Zacarias Transmitted Via E-Mail
Village of Tequesta nzacarias@tequesta.org
345 Tequesta Drive
Tequesta, FL 33469
RE: VILLAGE of TEQUESTA ANNEXATION AREAS "C" AND SANDPOINT BAY
CONDOMINIUM
Dear Nilsa Zacarias:
We have reviewed your request for the preparation of legal description and sketches on the
above referenced areas (as discussed in our office, dated 3/22/2013).The fee for said services
shall be $ 1900.00 and shall be completed within 30 days of authorization to commence.
Invoice shall be submitted upon completion of said work and payment will be expected within
thirty (30) days of invoice date. This proposal is subject to review and re-evaluation one (1)
year from the date of said proposal.
We thank you for considering this firm to pe�form the above outlined services. 1f there are any
questions concerning this proposal, please do not hesitate to call.
If this proposal meets with your approval, please have the person responsible for payment
return one (1) signed copy to this office; where upon receipt it wil� be deemed a contractual
agreement between signing
�
B : � , Date: 3/22/2013
D� . Dailey, P� .
/ /
Accepted by: a . Y �
Please print name and title
__
TH/S FORM HAS FIELDS YOU CAN TAB THROUGH TO COMPLETE
EMS MATCHiNG GRANT APPL/CATION
FLORIDA DEPARTMENT OF HEALTH
� Bureau of Emergency Medica/ Services
Complete all items uMess instructed different/y within the application
T e of Grant Re uested: ❑ Rural � Matchin
ID. Code The State Bureau of EMS wilt assi n the ID Code — leave this blank
1. Or anization Name: Te uesta Fire Rescue
2. Grant Signer; (The applicant signatory who has authoriry to sign contracts, grants, and other legal
documents. This individual must also sign this application)
Name: Michael Couzzo
Position Title: �Ila e Mana er
Address: 345 Te uesta Dr
Cit : Te uesta Count : Palm Beach
State: Florida Zi Code: 33469
Tele hone: 561-768-0465 Fax Number: 561-768-0697
E-Mail Address: MCouzzo Te uesta.or
3. Contact Person: (The individual with direct knowledge of the project on a day-to-day basis arod
responsibility for the implementation of the grant activities. This person may sign project reports and
may request project changes. The signer and the contact person may be the same.)
Name: Peter J. Allen
Position Title: Public Information Officer
Address: 357 Te uesta Dr.
Cit : Te uesta Count : Palm Beach
State: Florida Zi Code: 33469
Tele hone: 561-768-0553 Fax Number: 561-768-0693
E-Mail Address: PAllen Te uesta.or
DH FORM 1767 [2�13] B4J-1.015, F.A.C.
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4. Leqal Status of Aaplicant Oraanization (Check onlK one response):
(1) � Private Not for Profit [Attach documentation-501 (3} m]
(2) 0 Private For Profit
(3) � City/MunicipalitylTownNillage
(4) [� County
(5) ❑ State
(6) ❑ Other (specify):
5. Federal Tax ID Number (Nine Diqit Number), VF 5�644_448'I__ _
6. EMS License Number: 5021 Type: ❑Transport ❑Non-transport �Both
7. Number of permitted vehicles by type: BLS 2 ALS Transport 1 ALS non-transport.
8. Type of Service (check one): ❑Rescue �Fire OThird Service (County or City Government,
nonfire) �Air ambulance: ❑Fixed wing ❑Rotowing ❑Both �Other (specifyl
9. Medical Director of licensed EMS provider: If this project is approved, I agree by signing below that I
will affirm my authority and responsibility for the use of all medical equipment and/or the provision of all
continuin4 EMS education in this project. [No signature is needed if inedical equipment and
professional EMS education are not in this project.]
Signature: Date:
Print/Type: Name of Director ponald Tanabe MD.
FL Med. Lic. No. ME 61426
Note: All organizations that are not ficensed EMS providers must obtain the signature of the medical
director of the licensed EMS provider responsible for EMS services in their area of operation for projects
that involve medical e ui ment and/or continuin EMS education.
If your activity is a research or evaluation project, omit Items 10,11,12,13, and skip to Item
IVumber 14. Otherwise, roceed to Item 10 and the followin items.
10. Justification Summarv: Provide on no more than three one sided, double spaced pages a summary
addressing this project, cavering each topic listed below.
A) Problem description (Provide a narrative of the problem or need);
8} Present situation (Describe how the situation is being handled now);
C) The proposed solution (Present your proposed solution);
D) Consequences if not funded {E�cplain what will happen if this project is not funded);
E) The geographic area to be addressed (Provide a narrative description of the geographic area);
F) The proposed time frames (Provide a list of the time ftame(s) for completing this project);
G) Data Sources (Provide a complete description of data source(s) you cite);
H) Statement attesting that the proposal is not a duplication of a previous effort (State that this project
doesn't duplicate what you've done on other grant projects under this grant program).
DH FORM 1767 [2013]
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Next, only complete one of the following: ttems 11,12, or 13. Read all three and then select and
complete the one that pertains the most to the preced'+ng Justificatlon Summary. Note that on all
three, Ehat before-after differences for emergency victim data are the highest scoring items on the
Matchin Grants Evaluation Worksheet used b reviewers to evaluate our a lication form.
11. Outcome For Proiects That Provide or Effect Direct Services To Emergencv Victims� This may
include vehicles, medical and rescue equipment, communications, navigation, dispatch, and all other
things that impact upon on-site treatment, rescue, and benefit of emergency victims at the emergency
scene. Use no more than two additional one sided, double-spaced pages for your response. Include the
following.
A) Quantify what the situation has been in the most recent 12 months for which you have data (include
the dates). The strongest data will include numbers of deaths and injuries during this time.
B) In the 12 months after this project's resources are on-line, estimate what the numbers you provided
under the preceding "(A)" shauld become.
C) Justify and explain how you derived the numbers in (A) and (B), above.
D) What other outcome of this project do you expect? Be quantitative and explain the derivation of your
figures.
E) How does this integrate into your agency's five year plan?
12. Outcome For Traininq Projects: This includes training of all types for the public, first responders, law
enforcement personnel, EMS and other healthcare staff. Use no more than two additional one sided,
double-spaced pages for your response. Include the following:
A) How many people received the training this project proposes in the most recent 12 month time period
for which you have data (include the dates).
B) How many people do you estimate will successfully complete this training in the 12 months after
training begins?
C) If this training is designed to have an impact on injuries, deaths, or other emergency victim data,
provide the impact data for the 12 months before the training and project what the data should be in
the 12 months after the training.
D) Explain the derivation of all figures.
E) How does this integrate into your agency's five year plan?
13. Outcome For Other Projects: This includes quality assurance, management, administrative, and
other. Provide numeric data in your responses, if possible, that bear directly upon the project and
emergency victim deaths, injuries, andlor other data. Use no more than two additional one sided, double-
spaced pages for your response. Include the following.
A) What has the situation been in the most recent 12 months for which you have data (include the
dates)?
B) What will the situation be in the 12 months after the project services are on-line?
C) If this project is designed to have an impact on injuries, deaths, or other emergency victim data,
provide the impact data for the 12 months before the project and what the data should be in the 12
months after the project.
D) Explain the derivation of all numbers.
E) How does this integrate into your agency's five year plan?
DH FORM 1767 [2013]
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Tequesta Fire-Rescue Matching Grant Applicafiion
11. A) Problem Description
Cardiovascular Disease (CVD), principally heart dise�se and strake, is the Nation's leading killer for both
men and women among all racial and ethnic groups. Almost 1 million Americans die of CVD each year, which
adds up to 42% of all deaths. Heart disease doesn't just kill the elderly — it is the leading cause of death for ALL
Americans age 35 and older. Heart disease is the leading cause of death in Florida as well. In 2008, over 54,000
Floridians died from CVD.
Prompt diagnosis and definidva treaxment is vital for positive outcomes. In surviving a heart attack, experts
say time is the single most important critical factor. While having a heart attack, the more time that lapses without
definitive treatment, the greater risk of long-term permanent disability or death. Accuraxe 12-Lead technologies that
can be transmitted to hospitals and quick patient transport will provide patients with the best outcomes, best chance
of survival, and best quality of life.
From January l, 2012 through December 31, 2012 Tequesta Fire Rescue (TFR) responded to 1,174 ca11s,
974 were medical responses. Of these 974 calls, 148 were patients with cardiac symptoms requiring the use of a
cardiac monitor defibrillator with 12-Lead EKG capability.
B) Present Situation
Currently Tequesta Fire-Rescue has a total of 3 cardiac monitors in service. All three are outdated Zoll M-
Series systems, which are at least 11 years old. T'hese machines are incapable of supporting live-time, dynamic 12-
Lead Electrocardiogram (ECG) analysis, providing CPR quality analysis or able to read the EKG rhythm through
CPR. They provide a slower and less accurate Blood Pressure reading and they are not as capable of cammunicating
with other devices. We currently cannot transmit patient data from the scene or during transport to the receiving
facility. That results in a delay in getting the patient into the Cath Lab in the case of an actual heart attack. These
Zoll units are no longer manufactured and repair parts are only available from 3` party vendors, if at a11. Quite
simply, advances in technology have created an opportunity to provide an enhanced level of care that we cannot
currently meet.
Tequesta Fire-Rescue Matching Grant Application
C) Proposed Solution
It is imperative to expedite coronary intervention and to have access to industry standard equipment.
Tequesta Fire-Rescue proposes to enhance the aging cardiac monitoring systems currently in-service with more
capable, multifunction cardiac monitors and defibrillation systems in our Advanced Life Support Ambulances and
Engine. Madern cardiac monitors can trim minutes from the diagnosis and treatment of heart attacks and other
diseases requiring constant patient monitoring. The latest cardiac monitors provide a multitude of cutting-edge
capabilities including: cutting-edge 121ead ECG analysis using the latest industry standard interpreta.tion to
immediately recognize and trea.t myocardial infarction; the ability to transmit diagnostic quality 121ead ECG to
hospitals, 12 lead displays on screen and on paper, automatic defibrillation via biphasic waveform at recommended
energy levels with shock advisory system , noninvasive cardiac pacing; noninvasive blood pressure monitosting with
artifact rejection and automatic measurement modes; pulse oximetry with simple finger probe offering accurate and
reliable oxygen saturation, carbon monoxide saturation and MetHemoglobin monitoring; end-tidal capnography for
both intubated and non-intubated patients; extensive data storage, transmission and retrieval capabilities;
electroluminescent display and improved display (backlit for sunny conditions) to enhance viewing of ECGs and
vital signs, CPR feedback to ensure accurate depth and rate af compressions, improved communications with other
devices using Wi-Fi, Bluetooth, and USB cellular, improved durability, and SOmm or 100mm printers to record
ECGs and patient care.
D) Consequences If Not Funded
Without the help of the State EMS Matching Grant we will not currently be able to fund this project.
Should this proj�t not receive funding the current standard of patient care will not be available to patients
experiencing a coronary event. Tequesta Fire-Rescue paramedics will not have the equipment necessary to monitor
coronary conditions, will lack additional vital monitoring capabilities and wiil not have the best technology to
transmit 12 lead EKG's to the hospita.l. Transmitting 12-lead ECG's from the field is instrumental in shortening the
door to balloon time as Physicians and Cardiologists are prepared for the patient arrival. Teyuesta Fire-Rescue will
have to continue to use our old, outdated monitors. Having unreliable equipment proposes the likelihood of
malfunction. It will take multiple years for Tequesta Fire Rescue to acquire monitors.
Tequesta Fire-Rescue Matching Grant Application
E) Geographic area to be addressed
The geographic area that will be covered is the Village of Tequesta which covers approxunately 2
square miles and surrounding areas when Tequesta Fire Rescue is requested for mutual aid. Surrounding areas
that we routinely respond to, include Jupiter Inlet Colony, Palm Beach County and Martin County.
� Proposed time frames
Upon the approval of funds, cardiac monitors will be ordered. It is estimated the units will arrive in eight
weeks from the date ordered. Training on the units will be completed in 30 days. The units will be implemented
I within 12 weeks of approval.
` G) Data Sources
' Heart Disease and Stroke Statistics-2005 Update, American Heart Association
2 Florida Department of Health, Office of Vital Statistics,
3 Tequesta Fire Rescue Computer Aided Dispatch
4 US Census Bureau 2010
I 5 Tequesta Fire Rescue Run Reports
� Statement not duplicated
This proposal is not a duplication of any previous grant submitted by Tequesta Fire Rescue
Tequesta Fire-Rescue Matching Grant Application
13. Outcome
A) Quantify what the situation has been in the most recent 12 months for which you have data
(include the dates). The strongest date will include numbers of deaths and injuries during this
time.
The data included in the following sections was derived from Tequesta Fire-Rescue run reports and the
computer aid� dispatch system. This information is required by the State and by the Tequesta Fire-Rescue QUQA
department. From January 1, 2012 to Decemher 31 2012 TFR responded to 1,174 ca.11s, 974 of those calls were
medical. Of those calls, 148 involved patients with cardia.c conditions requiring the non-invasive use of a cardiac
monitor.
Our call volume increased 5.2% over the last year and 63% since we purchased the current Zoll EKG
Monitors and the trend is expe�ted to continue. The area we serve has seen an increase in our elderly population and
as with the entire state the number of overweight people is also increasing. Both sectors of the population have
shown to have higher incidences of �cardiac related problems.
AHA guidelines and our local protocols recommend all patients who are having chest pain should have 12-
lead ECG and a positive result should be transmitted to a Cardiac Specialty Hospital.
B) In the 12 months after this project's resources are on-line, estimate what the numbers you
provided under the proceeding "(A)" should become.
After this project has been implemented the numbers in (A) are likely to increase as our call volume
continues to increase. Implementation of the new cardiac monitors will allow TFR to run 12-leads on every patient
presenting with cardiac symptoms and transmit them in a timely manner to receiving facilities. It is estimated that
the scene to balloon time will decrease 20%.
C) Justify and explain how you derived the numbers in (A) and (B), above.
The data that is supplied in Item A and Item B is obtained from TFR run reports, Computer Aided Dispatch
I system, and AHA guidelines. The decrease in scene to balloon time was calculated based on the number of 12-leads
that will be transmitted while en route with new technology. Providing a diagnostic 12-lead, prior to arrival at the
hospital, will enable the patient to bypass the ED and go directly to the cath lab.
D) What other outcome of this project do you expect? Be quanNtative and explain the derivation of
your figures.
Tequesta Fire-Rescue Matching Grant Application
Replacing the outdated monitors will significantly reduce repair costs. It will also ensure that an ambulance will not
need to be ta.ken out of service until replacement parts can be located to repair the broken monitor. With the
approval of this grant TFR will be able to increase the standard of care to the residents of the Village of Tequesta.
The 121ead monitors will allow paramedics the ability to gain critical information on patients, not only cardiac
patients but also those with respiratoty compromise. It is expected that morale will also increase as industry
standard equipment will be implemented and Paramedics will be able to provide enhanced care.
E) How does this integrate into your agency's five year plan.
TFR's 5 year plan includes increasing the level of care to patients. The need for more up to daxe equipment
is recognized in our 5 year plan.
Skip Item 14 and go to Item 15, unfess your project is research and evaluation and you have not
cvmpleted the preceding Justification Summa and one outcome item.
14. Research and Evaluation Justification Summarv. and Outcome: You may use no more than three
additional one sided, double spaced pages for this item.
A) Justify the need for this project as it relates to EMS.
B) Identify (1) location and (2) population to which this research pertains.
C) Among population identified in 14(B) above, specify a past time frame, and provide the number of
deaths, injuries, or other adverse conditions during this time that you estimate the practical
application of this research will reduce (or positive effect that it will increase).
D) (1) Provide the expected numeric change when the anticipated findings of this project are placed into
practical use.
(2) Explain the basis for your estimates.
E) State your hypothesis.
F) Provide the method and design for this project.
G) Attach any questionnaires or involved documents that will be used.
Ft) !f human or other living subjects are involved in this research, provide documentatian that you will
comply with all applicable federal and state laws regarding research subje�ts.
I) Describe how you will collect and analyze the data.
ALL APPLICANTS MUST COMPLETE ITEM 15.
15. Statutorv Considerations and Criteria: The following are based on s. 401.113(2)(b) and 401.117,
F.S. Use no more than one additional double spaced page to complete this item. Write N/A for those
things in this section that do not pertain to this project. Respond to all others.
Justify that this project will:
A) Serve the requirements of the population upon which it will impact.
B) Enable emergency vehicles and their staff to conform to state standards established by law or rule of
the department.
C) Enable the vehicles of your organization to contain at least the minimum equipment and supplies as
required by law, rule or regulation of the department.
D) Enable the vehicles of you� organization to have, at a minimum, a direct communications linkup with
the operating base and hospital designated as the primary receiving facility.
E) Enable your organization to improve or expand the provision of:
1) EMS services on a county, multi county, or area wide basis.
2) Single EMS provider or coordinated methods of delivering services.
3) Coordination of all EMS communication links, with police, fire, emergency vehic�es, and other
related services.
DH FORM 1767 [2013]
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Tequesta Fire-Rescue Matching Grant Application
15. Statutory Considerallons and criteria:
Justify that this project will:
A) Serve the requirement of the popul$tion upon which it will impact
This project will enhance the care provided to cardiac patients in our axea and improve medical
outcomes and quality of life for the citizens we serve.
B) Enable emergency vehicles to conform to state standards established by law or rule of the
department
Having Capnography built into the Cardiac monitor will conform to state standa.rds.
C) Enable the vehicles of your organization to contain at least minimum equipment and supplies as
required by loa, rule or regulation of the department
This project will improve the Standard of Care and provide the equipment that is required by the Florida
Department of Health. It conforms to state standards to provide a monitor defibrillator with ECG print out and the
requirement for electronic waveform capnography capabLe of real time 12-Lead EKG monitoring and printing.
D) Enable the vehicles of your organization to have, at a minimum, a direct communications linkup
with the operating base and hospital designated as the primary receiving facility
Yes. The cardiac monitors are Bluetooth and USB cellular capable and will be able to transmit a diagnostic
ECG to the receiving facility.
E) Enable organization to improve or expand
Implementation of this equipment will enhance 12- lead patient service on a citywide basis. The equipment
requested will allow for communication and data transfer with all cardiac monitor products in service. The
availability for the equipment to speak to each other will allow data analysis which will lead to better patient care
and protocols when dealing with cardiac emergencies.
16. Work activities and time frames: Indicate the major activities for completing the project (use only the
space provided). Be reasonable, most projects cannot be completed in less than six months and if it is a
communications project, it wil{ take about a year. Also, if you are purchasing certain makes of
ambulances, it takes at least nine months for them to be delivered after the bid 9s let.
Work Activity Number of Months After Grant Starts
Be in End
MMIDD/YYYY MM/DD/YYYY
Purchase and Receive ZoN Monitors 6I0112013 08/01/2013
rain on Monitors 08/02/2013 09/01/2013
Place Monitors in Service 9/01/2013 09/01/2013
17. County Governments: If this application is being submitted by a county agency, describe in the
space below why this request cannot be paid for out of funds awarded under the state EMS county grant
program. Include in the explanation why any unspent county grant funds, which are now in your county
accounts, cannot be allocated in whole or part for the costs herein.
DH FORM 1767 [2013]
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18. Bud et:
Salaries and Bene�ts: Foc each Costs Justificatlon: Provide a brief justification
position title, provide the amount why each of the positions and the numbers
of salary per hour, FICA per hour, of hours are necessary for this project.
fringe benefits, and the total
number of hours.
N/A
TOTAL: 0.04 Right click on 0.00 then left click on
"Update Field" to calculate Total
Expenses: These are travel costs Costs: List the price Justification: Justify why each of the
and the usual, ordinary, and and source(s} of the expense items and quantities are
incidental expenditures by an price identified. necessary to this project.
agency, such as, comrnodities and
supplies of a consumable nature,
excludinq expenditures classified
as operating capital outlay (see
next cate o
NIA
TOTAL: 0.00 Right cl�ck on 0.00 then feft ciick on
�Update Field" to calculate Total
QH FORM 1767 [2013]
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Vehicles, equipment, and other Costs: List the price Justification: State why each of the items
operating capital outlay means of the item and the and quantities listed is a necessary
equipment, fixtures, and other source(s} used to component of this project.
tangible pe�sonal property of a non identify the price.
consumable and non expendable
nature, and the normal expected
life of which is 1 ear or more.
3 Cardiac monitors with 97,203.09 One monitor for each ALS unit. Pricing from
accessories vendor uot
TOTAL: 97 203.09 Right click on 0.00 then feft click on
"Update Field" to calculate Total
State Amount
(Check applicable program)
Right click on 0.00 then left click on
� Matching: 75 Percent 72 g42.32 "Update Field" to calculate Total
Right click on 0.00 then left click on
❑ Rural: 90 Percent
0.00 �Update Field" to calculate Total
Local Match Amount
(Check applicable program)
Right click on 0.00 then left click on
� Matching: 25 Percent "Update Field" to calculate Tota!
24 300.77
Right click on 0.0a then left click on
❑ Rural: 10 Percent
0.00 ��Update Field° to calcufate Total
Grand Totat Right click on 0.00 then left click on
DH FORM 1767 [2013]
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- _._ _ _ _ _ _ _._ _ ._
19. Certification
y signature below certifies the following.
I am aware that any omissions, falsifications, misstatements, or misrepresentations in this
application may disqualify me for this grant and, if funded, may be grounds for termination at a
. later date. 1 understand that any information I give may be investigated as allowed by taw. I
certify that to the best of my knowledge and belief all of the statements coritained herein and on
ny attachments are true, co�rect, complete, and made in good faith.
__ ____ __ _ _._ _.__ _ _ _ __ _ _ - ___. _ _ . --- .._ _ — --- _ _ .
I agree that any and all information submitted in this application will become a public documen#
pursuant to Section 119.07, F.S. when received by the Florida Bureau of EMS. This includes
material which the appticant might consider to be confidential or a trade secret. Any claim of
onfidentiality is waived by the applicant upon submission of this application pursuant to Section
119.07,F.S., effective after opening by the Florida Bureau of EMS.
1 accept that in the best interests of the State, the Florida Bureau of EMS reserves the right to
reject or revise any and all grant proposals or waive any minor irregularity or technicality in
proposafs received, and can exercise that right.
I, the undersigned, understand and accept that the Notice of Matching Grarrt Awards wili be
advertised in the Florida Rdministrative Weekly, and that 21 days after this advertisemerrt is
ublished I waive any right to challenge or protest the awards pursuant to Chapter 120, F.S.
___ _ _ _ --_ _ _ _ _ _ _ _ _ _ __ _ . _ _ _ --_ _ __. _ _ _ _ .
f certify that the cash match will be expended befinreen the beginning and ending dates of the
rant and will be used in strict accordance with the conterit of the application and approved
budget for the activities ident'rfieci. In addition, the budget shall not exceed, the department,
approved funds for those activities identified in the notification letter. No funds count towards
satisfying this grant if the funds were also used to satisfy a matching requirement of anotF�er state
rant. All cash, salaries, firinge benefits, expenses, equipment, and other expenses as listed in
his application shal{ be committed and used for the activit+es approved as a part of this grant.
cceptance of Terms and Conditions: If awarded a g�ant, I certify that I will c+omply with a{I of the
above and also accept the attached grant terms and conditions and adcnowledge this by signing
below.
f / !'-�v�
Signature ofi Authorized , Grant Signer M! DD f YY
Individual Identified in Item 2
DH FORM 1767 [2013]
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THE TOP PAR7 OF THE FOLLOWIPIG PAGE MUST ALSO BE COMPLETED ANQ SIGNED.
FLORIDA DEPARTMENT OF HEALTH
EMS GrraNr PrzoGRaM
REQUEST FOR GRANT FUND DISTRIBUTION
' In accordance with the provisions of Section 401.113(2)(b), F. S., the undersigned hereby
requests an EMS grant fund distribution for the improvement and expansion or continuation of
pre-hospital EMS.
DOH Remit Pavment To;
Name of Agency: Tequssta Fire Rescue
Mailing Address: 357 Tequesta Dr.
Tequesta, FL
33469
Federal Identification Number 596044081
Authorized Agency Official: � ,r�
Signature ate
Michael Couzzo, Village Manager
Type Name and Title
Sign and return this page with your application to:
Florida Department af Health
BEMS Grant Program
4052 Bald Cypress Way, Bin C18
Tal/ahassee, Florida 32399-1738
Do not write below this line. For use by Bureau of Emergency Medical Seroices personnel only
Grant Amount For State To Pay: $ Grant ID Code:
Approved By:
Signature of State EMS Grant Officer Date
State Fiscal Year. -
Organization Code E�O. QCA Obiect Code
64-42-10-00-000 03 SF003 750000
Federal Tax ID: VF
Grant Beginning Date: Grant Ending Date:
D F 1 p
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