HomeMy WebLinkAboutbocc.con.076.2000 APPROVED BY BOCC
ON # -
COUNTY SUBSIDY PAYMENT DISTRIBUTION FORM
COLORADO EMERGENCY MEDICAL SERVICES SUBSIDY PROGRAM FOR
COUNTIES
In accordance with the provision of CRS 23-3.5-605, the undersigned hereby requests and EMS
county subsidy distribution payment for the improvement and expansion of prehospital EMS. It
is understood that payment is contingent upon approval of the statutory reporting requirement by
the state advisory council on EMS.
Payment to: Board of County Commissioners Pitkin County
Name of Board of County Cormmssioners(payee)
401 Castle Creek Road
Address
Aspen Colorado 81611
(City) (State) (Zip)
Chairperson Board of County Commissioners
SIGNATURE: wrry - ) DATE:
n e
Printed Name: 1 1 i t C
SIGN AND RETURN THIS FO ALONG WITH ALL REPORTING DOCUMENTATION
For use only by Department of Public Health and Environment
Amount: $15,092.33
Approved by: Date:
Grants Manager
Date:
Fiscal Officer
Fund A¢encv Org Aoor Code Func ON GBL
408 FLA 8300 839 FLWT 5120 001S
Original Contract Number: 9807588
Renewal Routing#: 100188
Vendor#: 846000794 F