HomeMy WebLinkAbout20110427.tiff RESOLUTION
RE: APPROVE APPLICATION FOR COLORADO EMTS PROVIDER GRANT AND
AUTHORIZE CHAIR TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with an Application for the Colorado EMTS
Provider Grant from the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Paramedic Service,to the Colorado Department of
Public Health and Environment, commencing upon full execution,with further terms and conditions
being as stated in said application, and
WHEREAS,after review,the Board deems it advisable to approve said application, a copy of
which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the Application for the Colorado EMTS Provider Grant from the County of
Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on
behalf of the Paramedic Service,to the Colorado Department of Public Health and Environment be,
and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said application.
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 9th day of February, A.D., 2011.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST: 0, ; i�%i�'� Ell / S ®ti
rbara Kirkmeyer hair
Weld County Clerk to the B d.` i (
t ` l •
BY:Oh , / an P. Co , Pro-Tem
a .(mot
Deputy Clerk to the Bo• `.�( I ��
m F. Gar 'a
AP O DASTO M: d� �� fs
David E. Long
/
ounty Attorney cYcr7 e,5 rev
Douglas Rademacher
Date of signature: 0060,20//
DV1 qc 4° Noe_
-H- II C bave- b 2011-0427
AM0020
EMTS Provider Grant Application Page 1 of!
ATTACHMENT A
CDPHE Use Only - Fiscal Year 2012
Colorado EMTS Provider Grant
Application
Colorado Department of Public Health and Environment
HFEMTSD-A2
4300 Cherry Creek Drive South
Denver,CO 80246-1530
RETAC Eval #
DRAFT
'Phis application is in draft form until it is submitted to the state.
1. Legal Name: Weld County Government 2. Federal Tax ID Number
Doing Business As: Weld County Paramedic Services 846000813
3 4 Phone Numbers
Grant Contact Person: Director David Bressler Day: 970-353-5700 Mobile:970-302-1127
E-mail: dbressler@co.weld.co.us Fax: 970-304-6408
5 6. This is a grant application that cannot be scored
Agency Mailing Address: at a RETAC hearing. Score this application at
915 10th Street, Greeley,CO 80631 the state SEMTAC level only.
No
7. (This is a multi-agency application:No I 8. (List the counties your grant project impacts:
9. !Please describe your overall grant request in ten sentences or less:
Replacement of an ambulance that was lost due to an accident. While attending to patients on Interstate 76 the Weld County
Ambulance was struck from behind. Damage to the vehicle exceeded the value of the ambulance and it was totalled. Weld County
received insurance funds that will be used as the 10%match for the replacment unit being applied for.
Request Categories
Agency Match: 10%
CDPHE Use Only
Agency Share State Share
PROJECT AREA SUMMARY Total Category Cost 10% 90% Amount Funded / SEMTAC
Eval g
1 Ambulance,Other Vehicle $154,215.00 $15,421.50 $138,793.50
!Grant Request Totals: $154,215.00 $15,421.50 $138,793.50
Grant Application History For Agency
Grant Fiscal Year Category 'Status
2011 EMSEquip Funded: $79,144.00
q p Spent: $13,799.56
Funded: $4,390.00
2010A EMSEquip Spent: $4,398.76
Funded: $49,750.00
2010A Veh
Spent: $46,777.50
2010 Veh Funded: $46,750.00
Spent: $46,350.00
2009 Veh Funded: $38,400.00
Spent: $38,400.00
Funded: $41,700.00
2008 Data
Spent: $40,500.00
2008 Veh Funded: $35,420.00
Spent: $31,200.00
https://www.hfemsd2.dphe.state.co.us/CEMSISWeb_Grants/frm_5102 PrintApp.aspx 2011-0427
EMTS Provider Grant Application Page 2 of!
MATRIX Data Submission Requirement
Its this agency currently participating in the statewide data collection system?Yes
Financial Narrative (REQUIRED)
Weld County Paramedic Services (WCPS) is owned and operated by the Board of County Commissioners of Weld
County. The agency being an enterprise fund is solely responsible for its budget and financial well being within the
County. The agency serves just under 4,000 square miles of North /Northeastern Colorado. Operating as an
enterprise of Weld County Government since 1989, WCPS is required to bill and collect the operational costs of
providing advanced life support treatment and transportation.
The service area and customer base includes a population that is over 50% Medicare, Medicaid, and medically
indigent. With the impact of the recent economic recession, the impact of the increasing indeigent and uninsured
population due to unemployment, the ambulance service struggles with the Medicare /Medicaid fee schedules and
associated collection rates. WCPS has experienced an unadjusted collection rate of approximately 30% over the last
three years. WCPS has continued to strictly monitor the budget along with decreasing certain items, including the
loss of staff postions. Efforts continue to improve overall effeciencies in our EPCR field data collection and
electronic billing of the citizens and visitors we serve and to stabilize the revenues shortfalls being experience. The
bad debt experienced in our accounts receivabless continues to grow as the demographics of our service area
struggles to meet the challenges with the difficult sutuation.
This uncollected debt adversely impacts our ability to maintain and purchase new equipment. Additionally our
ability to maintain and improve our service delivery in the care of STEMI /Cardiac Arrest patients and trauma
services draws from the same fundign source. WCPS has worked deligently over the years as an enterpise of county
government to maintain a responsbile budget. With the increasing amount of bad dept and federal fee schedules; the
strain being placed on the budget for replacement of vehicles and the purchase of captial equipment has increased
substantially. The end result is a negative impact on our scheduled replacement of ambulance units. WCPS has had
to lengthen the service life of our ambulances through a rechassis program until recently. WCPS experienced the
unexpected loss of a unit while on scene of a traffic accident. This resulted in the loss of a vehicle before it scheduled
replacement. This application is our way of meeting that unbudgeted need.
Thank you.
tyrant ttequest categories
Category I - Ambulance, Other Vehicle
'Category I -Ambulance,Other Vehicle(Request Details)
Qty Description I Price Each Agency Share State Share Amount Funded
III ; 2 wd
I 2011 G4500 Model Year Ambulance-Lifeline Superliner $154,215.00 $15,421.50 $138,793.50
Replacement
I Totals $15,421.50 $138,793.501
Category I - Ambulance, Other Vehicle (Additional Questions)
If the requested vehicle(s) is(are)replacement(s):
If a replacement, number of days the
1 0
unit was out of service?
https://www.hfemsd2.dphe.state.co.us/CEMSISWeb_Grants/frm_5102_PrintApp.aspx 2/4/201
EMTS Provider Grant Application Page 3 of
What will be done with the unit that is
2. replaced—sold, traded, donated, etc.? Sold through insurance settlement.
td>
What is the average length of service, in
3. miles and or years, of vehicles operated 4 Years
by your agency'?
Describe your front line and back up WCPS has twelve (12) front line units. Deployment varies throughout
4. rotations: the day and year by demand. We maintain and agressive preventative
maintenance program with service every 3,000 miles.
Category I -Ambulance, Other Vehicle (Narratives)
Ambulances are replaced on a three to four year schedule. Miles, hours and cost per
mile are evaluated by the Management Team and Fleet Coordinator at the Paramedic
Please describe your
Services in coordination with the Weld County Controller/Fleet Manager. The private
agency's vehicle
vendor provides oversight and record keeping of all maintenance and repair costs for
replacement program.
budgetary review prior to a recommendation on which vehicles are retired and
replaced.
This vehicle will replace a vehicle lost prematurely in an accident where it was struck
Vehicle request narrative and damaged beyond repair. All interior equipment will be salvaged and moved to the
replacement vehicle.
Attestation
I. Legal Name of Agency: Weld County Government
2. DBA (Doing Business As - If Applicable: Weld County Paramedic Services
3. Federal Tax ID Number: 846000813
4. Grant Contact Person:
4a. Title: Director
4b. First Name: David
4c. Last Name: Bressler
Authorized Agent
The individual whose name and signature appear below, has been designated by the agency/organization listed above
as the Authorized Agent to complete and submit this grant application on its behalf. The agency/organization agrees
to comply with the rules and regulations governing the State of Colorado EMTS Grants Program concerning grant
https://www.hfemsd2.dphe.state.co.us/CEMSISWeb_Grants/frm 5102_PrintApp.aspx 2/4/201
EMTS Provider Grant Application Page 4 of
requests.
Financial Information
The Authorized Agent attests to the agency or organization's ability to provide the matching funds (50%, 40%,
5' 30%, 20% or 10%) to complete the purchase of the grant award, should the agency be awarded state funds.
The Authorized Agent is aware that vehicles and equipment purchased must be without any financial liens and
6
without the item being used as collateral to secure a loan of any kind.
The Authorized Agent attests that, to the best of his/her knowledge, the information contained herein, with regard
7. to the Agency's financial condition, is true, accurate and correctly reflects the financial condition of the
agency/organization.
Notification of Affected Entities
By signing below, the Authorized Agent also attests to the fact that:
The agency(ies)/organization(s) affected by the possible outcome of this grant request, including but not limited to
8. agencies/organizations listed in this application if it is a multi-agency application, has(have) been notified and has
(have) agreed to its submission.
Applicant Duties and Obligations Should Funding be Awarded
Should the agency/organization listed in this application receive funding under this grant application, the
agency/organization (hereinafter referred to as 'grantee') shall, and affirmatively promises to, comply with all of the
provisions set forth below.
The grantee shall use grant funds received under this grant to complete all aspects of its grant application, and
9' shall not use such funds for purposes other than this.
The grantee shall submit quarterly progress reports to the Colorado Department of Public Health and
10. Environment, EMTS Category (hereinafter referred to as 'the State')
11. Requirements for Training and Education Grants
For any training or education requests funded from this application the grantee shall comply with the following terms
and conditions:
Reimbursement for all travel expenses associated with the training or education program shall be made in
A. accordance with the then current state of Colorado reimbursement rates for travel as specified in the Fiscal
Rules of the state of Colorado.
Written proof of the successful completion of any training or educational program shall be submitted at the
B
same time as the invoice requesting reimbursement for that training or educational program.
C. Prompt billing at the end of each quarter or semester is expected.
If the grantee provides a training or educational program, then the grantee shall acknowledge the use of
emergency medical and trauma services account grant funds in all public service announcements, program
D. announcements, or any other printed material used for the purpose of promoting or advertising the training or
educational program.
If the grantee provides a training or educational program, then the grantee shall develop and utilize a course
E. evaluation tool to measure the effectiveness of that training or educational program. The grantee shall submit
a copy of all evaluation reports to the State upon completion of the training or educational program.
12. Requirements for Equipment Grants
For any equipment purchases funded from this application, the grantee shall comply with the following requirements.
A. The grantee shall provide the state with written documentation of the purchase of the specified equipment.
All communications equipment shall be purchased from the State award for communications equipment, or
from another vendor for a comparable price and quality. If the grantee desires to purchase communications
equipment which is not listed on the State award then the grantee must complete, with the State's assistance
B. if needed, an informal competitive solicitation process before purchasing that equipment. If a competitive
solicitation process is used, then the grantee shall purchase the communications equipment from the lowest
bidder whose bid meets the bid specifications.
https://www.hfemsd2.dphe.state.co.us/CEMSISWeb_Grants/frm_5102_PrintApp.aspx 2/4/201
EMTS Provider Grant Application Page 5 of
If the grantee desires to purchase emergency vehicles other than ambulances, then the grantee must complete,
with the State's assistance if needed, an informal competitive solicitation process before purchasing that
equipment. The proposed specifications for these emergency vehicles must be approved by the State prior to
C
the initiation of the informal competitive solicitation process. If a competitive solicitation process is used,
then the grantee shall purchase the emergency vehicles from the lowest bidder whose bid meets the bid
specifications.
If the grantee desires to purchase medical equipment, then the grantee must complete, with the State's
D assistance if needed, an informal competitive solicitation process before purchasing that equipment. If a
competitive solicitation process is used, then the grantee shall purchase the medical equipment from the
lowest bidder whose bid meets the bid specifications.
During the initial term and any renewal or extension term of the contract or purchase order issued to convey
E funding to the grantee, and after the cancellation, termination, or expiration date of said contract or purchase
order, the grantee shall acquire and maintain personal property casualty insurance for the replacement value
of all equipment it purchases under this grant for the useful life of that purchased equipment.
F The grantee shall keep inventory control records for all equipment it purchases. The grantee shall obtain the
prior, express, written consent of the State before relocating or reallocating any equipment it purchases.
The grantee shall provide the State with a picture of each piece of equipment it purchases. The grantee may
G. submit a picture of a piece of purchased equipment at any time, but in no event no later than the date the
grantee's final progress report is due to the State.
The grantee shall maintain all equipment it purchases in good working order, normal wear and tear excepted.
The grantee shall perform all necessary maintenance services for all equipment it purchases in a timely
H. manner and in accordance with all manufacturer's specifications and all manufacturer's warranty
requirements. The grantee shall keep detailed and accurate records of all maintenance services it performs on
all equipment it purchases.
I The grantee shall repair or replace all purchased equipment which is damaged, destroyed, lost, stolen, or
involved in any other form of casualty.
If the grantee ceases to provide emergency medical and trauma services in the state of Colorado, then all
equipment purchased under this grant shall either be placed with another operating emergency medical
j. services provider in the state of Colorado, or be sold at public auction for its then fair market value. That
portion of the sale proceeds which equals the State's initial financial contribution towards the purchase of that
equipment shall be refunded to the State by the grantee. The grantee shall obtain the prior, express written
consent of the State prior to any relocation or sale of any purchased equipment.
Authorized Agent
13. First Name Barbara
14. Last Name Kirkmeyer
15. Title Chairman
16. Daytime Phone Number 970-356-4000
17. Daytime Phone Number Extension X4200
18. Date FEB 0 0 2011
19. Signature of Authorized Agent
Documents Received via Electronic Submission:
010H—oq 7
File Name Date Created File Size (kb) Click to Delete
https://www.hfemsd2.dphe.state.co.us/CEMSISWeb_Grants/frm_5102 PrintApp.aspx 2/4/201
EMTS Provider Grant Application Page 6 of t
I52700028.pdf 2/4/2011 11,603 Delete
15270028.pdf 2/4/2011 9,194 Delete
2009 CAFR.pdf 2/4/2011 2,865 Delete
3029-31 Greeley, CO.pdf 2/3/2011 521 Delete
Weld Cnty Safety Items pricing.pdf 2/3/2011 119 Delete
Weld County Final Line item.pdf 2/3/2011 54 Delete
Weld County Pricing Grant Letter.pdf 2/3/2011 112 Delete
Agency Profile
Organization Data
A.Agency/Facility Information
I. Legal Name of Organization: Weld County Paramedic Services
ID Number: 322
Profile Year: 2011
Submission Date: 1/31/2011
2. DBA Name: Weld County Paramedic Services
3a. Physical Address: 1121 M St
Greeley, CO 80631
Physical County: Weld
3b. Mailing Address: 1121 M St
Greeley, CO 80631
4. Person Filling out this Profile: DAVID W BRESSLER
5. Main Phone Number: 970-353-5700 ext 3211
6. Fax Phone: 970-304-6408
7. E-Mail: dbressler@co.weld.co.us
8. Web Site: www.co.weld.co.us/departments/paramedic services/ambulance.htm
9. 24 Hour Phone Number: 970-302-2833
10. RETAC Affiliated With: Northeast Colorado
B.Organization Types
1. EMS Response: Yes
2. Medical Facility: No
3. EMS Education Program: No
4. County Government (non-response): No
5 RETAC: No
6. Association / Foundation / Other: No
C.Service Area
1. Briefly describe the geographic area Weld County Paramedic Services is the primary advanced life
served by your organization: support licensed transport agency in Weld County Colorado except
in the following areas. Frederick Firestone and Mountain View Fire
Departments provide ambulance coverage is their fire districts, along
https://www.hfemsd2.dphe.state.co.us/CEMSISWeb_Grants/frm 5102_PrintApp.aspx 2/4/201
EMTS Provider Grant Application Page 7 of 1
with Platte Valley EMS from Brighton Colorado responding north to
Weld County Road 6 with the Greater Brighton Fire District.
EMS Contacts
A.EMS Organization
1. EMS Organization Name: Weld County Paramedic Services
2. Licensing:
Is this organization a county licensed Yes
ground ambulance service?
Is this organization a Colorado licensed air No
ambulance service?
B.EMS Service Director
1. Director's Name: David W Bressler
2. Mailing Address: 1121 M St
Greeley, CO 80631
3. Work Phone Number: 970-353-5700 ext. 3211
4. E-Mail: dbressler@co.weld.co.us
C.EMS Alternate Contact
1. Alternate Contact's Name: Mitch E Wagy
2. E-Mail: mwagy@co.weld.co.us
D.EMS Medical Director
1. Medical Director's Name: Kitagawa
2. Mailing Address: 1121 M St
Greeley, CO 80631
3. Primary Phone Number: 970-353-5700 ext. 3211
4. E-Mail: bkitagawa@co.weld.co.us
5. Colorado Medical License Number: 30531
Services and Structure
1. Organizational Structure: County government
2. Corporate/ Tax Status: government
3. Funding Types: Patient fees,
State grant,
Federal grant
4. Billing Method: Agency - In-house
5. Primary service provided by your EMS Scene response with transport
Organization:
6. Other services provided by your EMS Scene response without transport,
organization: lnterfacility transport,
Convalescent medical transport
7. What level of provider can your service Paramedic
send to EVERY call?
https://www.hfemsd2.dphe.state.co.us/CEMSISWeb_Grants/frm_5102_PrintApp.aspx 2/4/201
EMTS Provider Grant Application Page 8 of!
Personnel
Category Full Time Part Time Volunteer Tota;
1. EMT-Basic 12 20 32
2. EMT-Intermediate 2 2
3. EMT-Paramedic 36 26 62
4. First Responder
5. Nurse
6. Medical Director or other Physician 1
Requests for EMS Services
A.Requests for Services
1. Emergency Response with Transport: 8,778
2. Emergency Response without Transport: 4,814
3. Non-Emergency Transport: 594
4. Standby: 54
5. Cancelled Calls: 1,425
6. Other:
7. Total: 15,665
B.EMS Financial Resources
1. Total Annual EMS Budget for this $5,700,000.00
Organization:
2. Total Annual EMS Charges Billed: $17,914,539.36
3. Total Annual EMS Charges Collected: $5,156,827.89
Counties Licensed In
1. List all counties where this agency is Weld
licensed for Ground transport services:
Vehicles
Unit Make / Model /Year Box Make Mileage Equipped All Type Bought Replacemen
Number For Wheel kkk.1822 with Year
Drive EMS
Funds
11- Ford/E350 / 2004 US Bus 4,855 BLS Other 2015
MiniBus
222- FORD / Expedition /2005 Ford 132,348 BLS Other 2012
EMSCom
28 Ford/E-450 / 2005 Braun 173,009 ALS 111 2010
31 Ford / E-350 / 2006 Braun 137,595 ALS III 2010
32-EMS! Ford/ E350 / 2006 Ford 155,214 BLS Other 2012
Va
33 Ford /E450 /2007 Braun 109,293 ALS III 2010
https://www.hfemsd2.dphe.state.co.us/CEMSISWeb_Grants/frm_5102_PrintApp.aspx 2/4/201
EMTS Provider Grant Application Page 9 of
34 Ford/ E450 / 2007 Braun 139,379 ALS III 2011
36 Ford / E450 / 2008 Braun 113,511 ALS III Yes 2011
37 Chevy / G4500/ 2009 Braun 64,688 ALS III Yes 2013
38 Chevy/G4500 /2009 Braun 38,518 ALS III 2013
39 Chevy/G4500 /2009 Lifeline 36,029 ALS III 2014
40 Chevy/ G4500 /2009 Lifeline 32,290 ALS III 2014
41 Chevy / G4500 / 2009 Lifeline 37,394 ALS III 2014
42 Chevy / G4500 / 2009 Lifeline 40,440 ALS III 2015
43 Chevy / G4500 / 2009 Braun 20,385 ALS III Yes 2015
EMS Ground Demographics
A.Demographics of Service Area for Ground Transport
1. Population Density / Urbanicity: Suburban
2. Employment Type: Paid
3. Number of stations for this Service: 4
4. Average Call Time (Dispatch to Back-In- 25.00 minutes
Service:):
5. Average patient mileage per transport: 16.00 miles
6. Total square miles of your primary service 3,992
area (land & water):
7. Estimated permanent population of your 254,759
primary service area:
B.System Participation
I. Ross (Colorado State Emergency Resource 322
Inventory Report) Agency ID Number:
2. Is your agency National Incident Yes
Management System (NIMS) compliant?
C.EMS Ground Billing Rates
1. BLS Emergency - HCPCS Code A0429: $1,570.00
2. ALS Emergency - HCPCS Code A0427: $1,812.00
3. ALS Level 2 —HCPCS Code A0433: $2,295.00
4. Specialty Care Transport— HCPCS Code $0.00
A0434:
5. Mileage Rate—HCPCS Code A0425: $20.00
Go Back
Colorado Department of Public Health and Environment
https://www.hfemsd2.dphe.state.co.us/CEMSISWeb_Grants/frm_5102_PrintApp.aspx 2/4/201
Form W-9 Request For Taxpayer Give form to the
Substitute Form Identification Number and Certification requestor. Do not
state of Colorado 5-2007 send to the IRS
Name EMPLOYEE N
Weld County Government
Business name,if different from above
aWeld County Paramedic Services
o Check appropriate box:
v ie
a C
T O r�I�
❑Individual/Sole Proprietor I_N:orponation O Partnership ❑x Other ►covez'rmeat Exempt from backup withholding
`o
` Address(numb(number,strestreet,and apt or sate no.) CDPHE Requester Name&Extension:
915 10th Street
vn City,state,and ZIP code.
w Greeley,CO S11631
Phone Number. List Account numbers)here(optional)
970-353-5700 rezTaxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.For individuals,this is your social security number(55N)However, Social Secuirty number
for a resident alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3.
For other entities,it is your employer identification number(EIN).If you do not have a number,see How to
get a TIN on page 3.
Employer identification number
Note:If the account is in more than one name,see the chart on page 4 for guidelines on
whose number to enter. 8 4 6 0 0 0 8 1 3
Part II Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me),and
2. I am not subject to backup withholding because.(a)I am exempt from backup withholding,or(b)I have not been notified by the
Internal Revenue Service(IRS)that I am subject to backup withholding as a result ofa failure to report all interest or dividends,or(c)
the IRS has notified me that I am no lonuer subiect to backup withholdine.and
3- I am a U.S.person(including a U.S.resident alien).
Certification instructions.You must cross out item 2 above if the IRS has notified you that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage
interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),
and generally,payments other than interest and dividends,you are not required to sign the Certification,but you must provide your correct TIN.
(See the instructions on page 3.)
Sign Signature of
Here U.S.person ► Date►
Minority and Women-owned Businesses(M/WBEs)Self Certification(Please check all boxes that apply)
In an effort to track levels of participation by women and minorities doing business with the State of Colorado,the following information is
requested.Please indicate the appropriate category of ownership for your company."Owned"in this context means a business that is at least
51 percent owned by an individual(s)who also control(s)and operate(s)it."Control"in this context means exercising the power to make policy
decisions."Operate"means actively involved in the day-to-day management.If your business is jointly owned by both men and women or is a
publicly held corporation,please check the box labeled"Not Applicable."
Gender Information:
❑ Female-Owned ❑ Male-Owned x❑ Not Applicable
Owner Ethnicity Information
OAfrican American ❑ Asian/Pacific American El Whie(non-Hispanic) ❑x Not Applicable
❑ Hispanic American ❑ Native American ❑ Other:
Small Business Information
Small Business(a business that is organized for profit,is independently owned and operated,and has 25 or fewer full time equivalent
employees.)
❑ Yes ❑x No
Page 2
Purpose of Form requester your correct TIN,make the proper
p Foreign person.If you are a foreign person,do certifications,and report all your taxable interest
A person who is required to file an information not use Form W-9.Instead,use the appropriate
return with the IRS,must obtain your correct nd dividends on your tax return.
Form W-8(see Publication 515,Withholding of ax
taxpayer identification number(TIN)to report, on Nonresident Aliens and Foreign Entities).
for example,income paid to you,real estate Payments you receive will be subject to
transactions,mortgage interest you paid, backup withholding if:
Nonresident alien who becomes a resident 1.You do not furnish your TIN to the requester,
acquisition or abandonment of secured property, alien.
cancellation of debt,or contributions you made 2.You do not certify your TIN when required
Generally,only a nonresident alien individual may
to an IRA. use the terms of a tax treaty to reduce or (see the Part II instructions on page 4 for details),
3.The IRS tells the requester that you furnished
eliminate U.S.tax on certain types of income. an incorrect TIN,
U.S.person.Use Form W-9 only if you are a However,most tax treaties contain a provision
U.S.person(including a resident alien),to 4.The IRS tells you that you are subject to
known as a"saving clause."Exceptions specified backup withholding because you did not report all
provide your correct TIN to the person in the saving clause may permit an exemption
requesting it(the requester)and,when your interest and dividends on your tax return(for
from tax to continue for certain types of income reportable interest and dividends only),or
applicable,to: even after the recipient has otherwise become a
1.Certify that the TIN you are giving is correct 5.You do not certify to the requester that you
U.S.resident alien for tax purposes.
(or you are waiting for a number to be issued), are not subject to backup withholding under 4
2.Certify that you are not subject to backup above(for reportable interest and dividend
If you are a U.S.resident alien who is relying on accounts opened after 1983 only).
withholding,or an exception contained in the saving clause of a
3.Claim exemption from backup withholding if Certain payees and payments are exempt from
tax treaty to claim an exemption from U.S.tax on backup withholding.See the instructions below
you are a U.S.exempt payee. certain types of income,you must attach a
In 3 above,if applicable,you are also and the separate Instructions for the Requester of
statement to Form W-9 that specifies the following Form W-9.
certifying that as a U.S.person,your allocable five items:
share of any partnership income from a U.S. Also see Special rules regarding partnerships on
1.The treaty country.Generally,this must be the page 1.
trade or business is not subject to the same treaty under which you claimed exemption
withholding tax on foreign partners'share of from tax as a nonresident alien.
effectively connected income. Penalties2.The treaty article addressing the income.
3.The article number(or location)in the tax Failure to furnish TIN.If you fail to furnish
Note.If a requester gives you a form other than treaty that contains the saving clause and its
your correct TIN to a requester,you are subject
Form W-9 to request your TIN,you must use the exceptions.
requester's form if it is substantially similar to to a penalty iso $50 u 0 reach ablech failure aandn unless
� 4.The type and amount of income that qualifies your failure is due to reasonable cause not to
this Form W-9. for the exemption from tax. willful neglect.
For federal tax purposes,you are considered 5.Sufficient facts to justify the exemption from
a person if you are: tax under the terms of the treaty article.
• An individual who is a citizen or resident of the Example.Article 20 of the U.S.-China income Civil penalty for false information with respect
United States, tax treaty allows an exemption from tax for to withholding.If you make a false statement
scholarship income received by a Chinese student with no reasonable basis that results in no backup
A partnership,corporation,company,or•
temporarily present in the United States.Under withholding,you arc subject to a 500 penalty.$
association created or organized in the United
U.S.law,this student will become a resident alien
States or under the laws of the United States,
for tax purposes if his or her stay in the United Criminal penalty for falsifying information.
States exceeds 5 calendar years. However, Willfully falsifying certifications or affirmations
• Any estate(other than a foreign estate)or paragraph 2 of the first Protocol to the U.S.-China may subject you to criminal penalties including
trust,See Regulations sections 301.7701-6(a) treaty(dated April 30,1984)allows the provisions nes and/or imprisonment.
and 7(a)for additional information. of Article 20 to continue to apply even after the
Special rules for partnerships.Partnerships Chinese student becomes a resident alien of the Misuse of TINS. If the requester discloses or uses
that conduct a trade or business in the United United States.A Chinese student who qualifies for
TINS in violation of federal law,the requester
this exception(under paragraph 2 of the first
States are generally required to pay a withholding
tax on any foreign partners'share of income from
may be subject to civil and criminal penalties.
protocol)and is relying on this exception to claim
an exemption from tax on his or her scholarship or
such business.Further,in certain cases where a
fellowship income would attach to Form W-9 a Specific Instructions
Form W-9 has not been received,a partnership is
statement that includes the information described
required to presume that a partner is a foreign
person,and pay the withholding tax.Therefore,if above to support that e Name
you are a U.S.person that is a partner in a
xemption.
partnership conducting a trade or business in the If you are a nonresident alien or a foreign entity If you are an individual,you must generally enter
United States,provide Form W-9 to the not subject to backup withholding,give the
the name shown on your income tax return.
partnership to establish your U.S.status and avoid equester the appropriate completed Form W-8.
However,if you have changed your last name,for
withholding n your share of partnership income. instance,due to marriage without informing the
What is backup withholding?Persons making Social Security Administration of the name change,
The person who gives Form W-9 to the certain payments to you must under certain enter your first name,the last name shown on
partnership for purposes of establishing its U.S. conditions withhold and pay to the IRS 28%of
your social security card,and your new last name.
such payments(after December 31,2002).This is
status and avoiding withholding on its allocable If the account is in joint names,list first,and
share of net income from the partnership called)backup withholding."Payments that may then circle,the name of the person or entity hose
conducting a trade or business in the United be subject to backup withholding include interest, number you entered in Part I of the form.
dividends,broker and barter exchange
States is in the following cases:
transactions,rents,royalties,nonemployee pay,
• The U.S.owner of a disregarded entity and Sole proprietor.Enter your individual name as
and certain payments from fishing boat operators. shown on your income tax return on the"Name"
not the entity, Real estate transactions are not subject to backup
• The U.S.grantor or other owner of a grantor line.You may enter your business,trade,or
withholding.
trust and not the trust,and "doing business as(DBA)"name on the Business
You will not be subject to backup withholding on name'line.
• The U.S.trust(other than a grantor trust) payments you receive if you give the
and not the beneficiaries of the trust.
Page 3
Limited Liability Company(LLC).If you are a 12.A common trust fund operated by a bank under get Form SS-5,Application for a Social
single-member LLC(including a foreign LLC with a section 584(a), Security Card,from your local Social
domestic owner)that is disregarded as an entity 13.A financial institution, Security Administration office or get this
separate from its owner under Treasury regulations 14.A middleman known in the investment form online at wwwsocialsecurity.gov.
section 301.7701-3,enter the owner's name on the community as a nominee or custodian,or You may also get this form by calling
"Name"line.Enter the LI.C's name on the 15.A trust exempt from tax under section 664 or 1-800-772-1213.Use Form W-7,
"Business name"line.Check the appropriate box for described in section 4947.The chart below shows Application for IRS Individual Taxpayer
your tiding status(sole proprietor,corporation,etc.), types of payments that may be exempt from backup Identification Number,to apply for an ITIN,
then check the box fur"Other"and enter"LLC"in withholding.The chart applies to the exempt or Form SS-4,Application for Employer
the space rovided.p Other entities.Enter your recipients listed above, I through 15. Identification Number,to apply for an FIN.
business name as shown on required federal tax You can apply for an EIN online by
documents on the"Name"line.This name should accessing the IRS website at
match the name shown on the charter or other legal www.irs.gov/businesses and clicking on
IF'the payment is for THEN the payment is Employer ID Numbers under Related
document creating the entity.You may enter any exempt for...
business,trade,or DNA name on the"Business .- Topics.You can get Forms W-7 and 55-4
name"line.Note.You are requested to check the Interest and dividend All exempt recients from the IRS by visiting www.irs.gov or by
pi
appropriate box for your status(individual/sole payments except for 9 calling 1-8o0-TAX-FORM
AX-FORM
proprietor,corporation,etc.). (I-800-829-3676).
Broker transactions Exempt recipients I If you are asked to complete Form W-9 but
Withholdingthrough 13.Also,a do not have a TIN,write"Applied For"in
Exempt Backup From person registered under the space for the TIN,sign and date the
the Investment Advisers form,and give it to the requester.For
If you are exempt,enter your name as described above interest and dividend payments,and certain
and check the appropriate box for your status,then check Act of 1940 who p y
regularly acts as a broker payments made with respect to readily
the"Exempt from backup withholding"box in the line tradable instruments,generally you will
following the business name,sign and date the form. Barter exchange Exempt recipients I have 60 days to get a TIN and give it to the
Generally,individuals(including sole proprietors)are
transactions and through 5 requester before you are subject to backup
not exempt from backup withholding.Corporations are patronage dividends withholding on payments.The 60-day rule
exempt from backup withholding for certain payments, does not apply to other types of payments.
such s interest and dividends. Payments over$600 Generally,exempt
You will be subject to backup withholding
required to be reported recipients l through 72
and direct sales over on all such payments until you provide your
Note.If you are exempt from backup withholding,youTIN to the equester r
should still complete this form to void possible erroneous $5,0001
backup withholding. Note.Writing"Applied For"means that you
Exempt payees.Backup withholding is not required on I.See Form 1099-MISC.,Miscellaneous Income,and its have already applied for a TIN or that you
nst
any payments made to the following payees: rumions. intend to pply for one soon.
I.An organization exempt from tax under section
2.However,the following payments made to a
501(a),any IRA,or a custodial account under section
corporation(including gross proceeds paid to an attorney Caution:A disregarded domestic entity that
403(6)(7)if the account satisfies the requirements of under section 60450,even if the attorney is a has a foreign owner must use the appropriate
section 401(f)(2), corporation)and reportable on Form 1099-MISC are not
2.The United States or any of its agencies or exempt from backup withholding:medical and health
instrumentalities, care payments,attorneys'fees:and payments for services
3.A state,the District of Columbia,a possession of the paid by a federal executive agency.
United States,or any of their political subdivisions or
instrumentalities, Part I. Taxpayer Identification
4.A foreign government or any of its political
subdivisions,agencies,or instrumentalities,or Number (TIN)
5.An international organization or any of its agencies or
Enter your TIN in the appropriate box. If you
instrumentalities.Other payees that may be exempt from
are a resident alien and you do not have and
backup withholding include:
are not eligible to get an SSN,your TIN is your
6.A corporation, IRS individual taxpayer identification number
7.A foreign central bank of issue, (ITIN). Enter it in the social security number
8.A dealer in securities or commodities required to box. If you do not have an ITIN, see How to get
register in the United States,the District of Columbia,or a TIN below. If you are a sole proprietor and
a possession of the United States, you have an EIN,you may enter either your
9.A futures commission merchant registered with the SSN or EIN. However,the IRS prefers that you
Commodity Futures Trading Commission, use your SSN. If you are a single-owner LLC
10.A real estate investment trust, that is disregarded as an entity separate from
I I.An entity registered at all times during the tax year its owner(see Limited liability company(LLC)
under the Investment Company Act of 1940, on page 2),enter your SSN (or EIN, if you have
one). If the LLC is a corporation, partnership,
etc.,enter the ntity's EIN.e Note. See the chart
on page 4 for further larification of name and
TIN combinations.c How to get a TIN. If you do
not have a TIN,apply for one immediately.To
Page 4
Part II.Certification
What Name and Number To Give the
To establish to the withholding agent that you are a U.S.
person,or resident alien,sign Form W-9.The Requester
withholding agent may request you to sign even if items For this type of account: Give name and SSN of:
I,4,and 5 below indicate therwise.
1. Individual The individual
2. Two or more individuals The actual owner of the
For a joint account,only the person whose IN is shown
(joint account) account or,if combined
in Part I should sign(when required).Exempt recipients;
funds,the first individual
see Exempt From Backup ithholding on page 2. I
on the account
3. Custodian account of a The minor 2
Signature requirements.Complete the ertification as
minor(Uniform Gift to
indicated in I through 5 below.
Minors Act)
4. a.The usual revocable The grantor-trustee t
1.Interest,dividend,and barter exchange accounts
savings trust(grantor is
opened before 1984 and broker accounts considered also trustee)
active during 1983.You must give your correct TIN,but The actual owner
you do not have o sign the certification. b. So-called trust account
that is not a legal or valid
2.Interest,dividend,broker,and barter exchange trust under state law
The owner a
accounts opened after 1983 and broker accounts 5. Sole proprietorship or
considered inactive during 1983. You must sign the single-owner LLC
certification or backup withholding will apply.If you are
subject to backup withholding and you are merely For this type of account: Give name and EIN of:
providing your correct TIN to the requester,you must 6, Sole proprietorship or The owner 3
cross out item 2 in the certification before signing the single-owner LLC
orm.
7. A valid trust,estate,or V
pension trust Legal entity
3.Real estate transactions.You must sign the
certification.You may cross out item 2 of the 8. Corporate or LLC The corporation
certification. electing corporate status
on Form 8832
4.Other payments.You must give your correct TIN,
but you do not have to sign the certification unless you 9 Association,club, The organization
have been notified that you have previously given an religious,charitable,
incorrect TIN."Other payments"include payments made educational,or other
in the course of the requester's trade or business for rents,
royalties,goods(other than bills for merchandise), 10. Partnership or The partnership
medical and health care services(including payments to multi-member LLC
corporations),payments to a nonemployee for services,
payments to certain fishing boat crew members and 11. A broker or registered The broker or nominee
fishermen,and gross proceeds paid to attorneys including nominee
payments to corporations).
12. Account with the The public entity
5.Mortgage interest paid by you,acquisition or Department of
abandonment of secured property,cancellation of Agriculture in the name
debt,qualified tuition program payments(under ofa public entity(such as
section 529),IRA,Coverdell ESA,Archer MSA or a state or local
USA contributions or distributions,and pension government,school
distributions.You must give your correct TIN,but you district,or prison)that
do not have to sign the certification. receives agricultural
program payments
1.List first and circle the name of the person whose number you
furnish.If only one person on a joint account has an SSN,that
person's number must be furnished.
2.Circle the minor's name and furnish the minor's SSN.
3.You must show your individual name and you may also enter your
business or"DBA"name on the second name line.You may use
either your SSN or EIN of you have one).If you are a sole
4.List first and circle the name of the legal trust,estate,or pension
trust.(Do not furnish the TIN of the personal representative or
trustee unless the legal entity itself is not designated in the account
Note.If no name is circled when more than
one name is listed,the number will be
considered to be that of the first name listed.
VENDOR DISCLOSER STATEMENT
Contract Performance Outside the United States or Colorado
Colorado Revised Statute 24-102-206
Contract or Purchase Order Routing Number:
(this line will be completed by the department)
Vendor Name: Weld County Paramedic Services
The person completing this form should be the business' President, Board Chairperson, Contract's
Authorized Signatory or the Purchase Order's Statement of Work Signatory.
This form shall be completed and returned to the contracting agency. This applies to all state contracts and
purchase orders for services executed after August 3, 2007.
1. Are any services under the contract or any subcontracts or purchase order anticipated to be performed
outside the United States or Colorado?
Yes ❑ No ❑
If"Yes",please complete the following two questions and then sign the form.
If"No",please sign the form.
2. Where will the services be performed under the contract, including any subcontracts or purchase order?
(List country(ies)and/or state(s).
3. Explain why it is necessary or advantageous to go outside of the United States or the State of Colorado to
perform the services under the contract or any subcontracts or purchase order.
Signature: ,Gt6t--t1 Printed Name: Barbara Kirkmeyer
Title: Chair, Weld County Board of Commissioners Date: 02/09/2011
CDPFIE VDS Form Page 1 of
EMTS Provider Grant - Attestation Page 1 of,
"-I 411-
7 :i" ,KrWW1 HATS Pro yid r ntA„ .C I1201l
ColoVVrado: wp d Comity P11 rr.,id r >r vi, ,322J
VV "'a Hy, Ise PP d dpi ed t if thr infgog tot do_ proici l r, is 3 r 1Ht er of g rl record F.I i Ire t�
rz .,. .-3"tFtgt4* provide cog [Of dog a, c Ito drirbawl, Ida,. (tom acly i1rpuci your gr ,o-runity to obi, ir. fa IC!ng
under this grant process.
Thursday,February 03,2011 4:32 PM
Grant Application
Attestation
1. Legal Name of Agency: Weld County Government
2. DBA (Doing Business As - If Applicable: Weld County Paramedic Services
3. Federal Tax ID Number: 846000813
4. Grant Contact Person:
4a. Title: Director
4b. First Name: David
4c. Last Name: Bressler
Authorized Agent
The individual whose name and signature appear below, has been designated by the agency/organization
listed above as the Authorized Agent to complete and submit this grant application on its behalf. The
agency/organization agrees to comply with the rules and regulations governing the State of Colorado
EMTS Grants Program concerning grant requests.
Financial Information
The Authorized Agent attests to the agency or organization's ability to provide the matching funds
5. (50%, 40%, 30%, 20% or 10%) to complete the purchase of the grant award, should the agency be
awarded state funds.
The Authorized Agent is aware that EMTS vehicles and equipment purchased must be without any
6. financial liens and without the item being used as collateral to secure a loan of any kind.
The Authorized Agent attests that, to the best of his/her knowledge, the information contained herein,
7. with regard to the Agency's financial condition, is true, accurate and correctly reflects the financial
condition of the agency/organization.
Notification of Affected Entities
By signing below, the Authorized Agent also attests to the fact that:
The agency(ies)/organization(s) affected by the possible outcome of this grant request, including but
8. not limited to agencies/organizations listed in this application if it is a multi-agency application, has
(have) been notified and has(have) agreed to its submission.
https://www.hfemsd2.dphe.state.co.us/CEMSISWeb_Grants/frm 3001_Grant Attest_PrintFriendly.aspx 2/3/201
EMTS Provider Grant - Attestation Page 2 of
Applicant Duties and Obligations Should Funding be Awarded
Should the agency/organization listed in this application receive funding under this grant application, the
agency/organization (hereinafter referred to as "grantee") shall, and affirmatively promises to, comply with
all of the provisions set forth below.
g The grantee shall use grant funds received under this grant to complete all aspects of its grant
application, and shall not use such funds for purposes other than this.
10. The grantee shall submit quarterly progress reports to the Colorado Department of Public Health and
Environment, EMTS Category (hereinafter referred to as 'the State').
11. Requirements for Training and Education Grants
For any training or education requests funded from this application the grantee shall comply with the
following terms and conditions:
Reimbursement for all travel expenses associated with the training or education program shall
A. be made in accordance with the then current state of Colorado reimbursement rates for travel as
specified in the Fiscal Rules of the state of Colorado.
Written proof of the successful completion of any training or educational program shall be
B. submitted at the same time as the invoice requesting reimbursement for that training or
educational program.
C. Prompt billing at the end of each quarter or semester is expected.
If the grantee provides a training or educational program, then the grantee shall acknowledge the
use of emergency medical and trauma services account grant funds in all public service
D
announcements, program announcements, or any other printed material used for the purpose of
promoting or advertising the training or educational program.
If the grantee provides a training or educational program, then the grantee shall develop and
E utilize a course evaluation tool to measure the effectiveness of that training or educational
program. The grantee shall submit a copy of all evaluation reports to the State upon completion
of the training or educational program.
12. Requirements for Equipment Grants
For any equipment purchases funded from this application, the grantee shall comply with the following
requirements.
The grantee shall provide the state with written documentation of the purchase of the specified
A
equipment.
All communications equipment shall be purchased from the State award for communications
equipment, or from another vendor for a comparable price and quality. If the grantee desires to
purchase communications equipment which is not listed on the State award then the grantee
B. must complete, with the State's assistance if needed, an informal competitive solicitation process
before purchasing that equipment. If a competitive solicitation process is used, then the grantee
shall purchase the communications equipment from the lowest bidder whose bid meets the bid
specifications.
If the grantee desires to purchase emergency vehicles other than ambulances, then the grantee
a must complete, with the State's assistance if needed, an informal competitive solicitation process
before purchasing that equipment. The proposed specifications for these emergency vehicles
must be approved by the State prior to the initiation of the informal competitive solicitation
https://www.hfemsd2.dphe.state.co.us/CEMSISWeb_Grants/frm 3001_Grant_Attest_PrintFriendly.aspx 2/3/201
EMTS Provider Grant- Attestation Page 3 of
process. If a competitive solicitation process is used, then the grantee shall purchase the
emergency vehicles from the lowest bidder whose bid meets the bid specifications.
If the grantee desires to purchase medical equipment, then the grantee must complete, with the
D State's assistance if needed, an informal competitive solicitation process before purchasing that
equipment. If a competitive solicitation process is used, then the grantee shall purchase the
medical equipment from the lowest bidder whose bid meets the bid specifications.
During the initial term and any renewal or extension term of the contract or purchase order
issued to convey funding to the grantee, and after the cancellation, termination, or expiration
E. date of said contract or purchase order, the grantee shall acquire and maintain personal property
casualty insurance for the replacement value of all equipment it purchases under this grant for
the useful life of that purchased equipment.
The grantee shall keep inventory control records for all equipment it purchases. The grantee
F. shall obtain the prior, express, written consent of the State before relocating or reallocating any
equipment it purchases.
The grantee shall provide the State with a picture of each piece of equipment it purchases. The
G. grantee may submit a picture of a piece of purchased equipment at any time, but in no event no
later than the date the grantee's final progress report is due to the State.
The grantee shall maintain all equipment it purchases in good working order, normal wear and
tear excepted. The grantee shall perform all necessary maintenance services for all equipment it
H. purchases in a timely manner and in accordance with all manufacturer's specifications and all
manufacturer's warranty requirements. The grantee shall keep detailed and accurate records of
all maintenance services it performs on all equipment it purchases.
The grantee shall repair or replace all purchased equipment which is damaged, destroyed, lost,
stolen, or involved in any other form of casualty.
If the grantee ceases to provide emergency medical and trauma services in the state of
Colorado, then all equipment purchased under this grant shall either be placed with another
operating emergency medical services provider in the state of Colorado, or be sold at public
J. auction for its then fair market value. That portion of the sale proceeds which equals the State's
initial financial contribution towards the purchase of that equipment shall be refunded to the
State by the grantee. The grantee shall obtain the prior, express written consent of the State
prior to any relocation or sale of any purchased equipment.
Authorized Agent
13. First Name Barbara
14. Last Name Kirkmeyer
15. Title Chairman
16. Daytime Phone Number 970-356-4000
17. Daytime Phone Number Extension 4200
18. Date FEB
0 B 2011
19. Signature of Authorized Agent 7444,6411
aa//— oUal
https://www.hfemsd2.dphe.state.co.us/CEMSISWeb_Grants/frm_3001_Grant Attest_PrintFriendly.aspx 2/3/201
EMTS Provider Grant - Attestation Page 4 of
Go Back
Colorado Department of Public Health and Environment
https://www.hfemsd2.dphe.state.co.us/CEMSISWeb_Grants/frm_3001_Grant Attest_PrintFriendly.aspx 2/3/201
EMTS Provider Grant Application Page 1 of 3
ATTACHMENT A
Colorado EMTS Provider Grant CDPHE Use Only Fiscal Year 2012
Application
Jeanne-Marie Bakehouse
Colorado Department of Public Health and Environment
HFEMTSD-A2
4300 Cherry Creek Drive South
Denver, CO 80246-1530
RETAC Eval #
Monday, February 14, 2011 3:05 PM
Weld County Paramedic Services
Please Print
Financial Waiver Application
1. Legal Name of Agency Weld County Government
2. Federal Tax ID Number 846000813
3. Grant Contact Person
3a. Title Director
3b. First Name David
3c. Last Name Bressler
3d. Daytime Phone 970-353-5700
3e. Mobile 970-302-1127
3f. Fax 970-304-6408
3g. Email Address dbressler@co.weld.co.us
Agency cash match percent for
this project.
4 This match percent was set on the 10
main grant application menu. If
you want to change it, you must
change it there.
Describe the financial situation of Weld County Paramedic Services has experienced an
your agency that indicates the increasing percentage of Medicaid, Medicare and Indigent
5. need for a waiver of the 50% cash population in our services area. With the recent economic
match requirement: situation and the unemployment rate in Weld County, an
increasing number of the population have relied on 911
,'ca-0LL27
mhtml:file://C:\Documents and Settings\jvanegdom\Local Settings\Temporary Internet File... 2/14/2011
EMTS Provider Grant Application Page 2 of 3
Paramedic Services for their health care. This is
(In the financial narrative section demonstrated in our CEMSIS Agency Profile with a financial
of the main grant application, you shortfall of "$500,000 for the operating year of 2010.
will be asked to provide a Additionally we had the unfortunate experience and
summary of your financial hardship of losing an ambulance involved in an accident
situation and any abnormalities in while on scene of a motor vehicle accident on Interstate
your financials. For example, 76. This ambulance is listed on our agency profile as Unit
excessive profit/loss, restricted #28 and suffered structural damage making it
funds, capital improvement items, unreasonable to repair. (This unit represents our oldest
balances showing as profit, etc.) unit, having been completed our rechassis program three
(3) times, representing "700,000 miles).
Describe efforts towards gaining
matching funds from Public or The insurance settlement will provide for the 10%
6. Private Entities Describe efforts matching funds for the replacement of this ambulance.
towards gaining matching funds
from Local or County Government
This agency has applied for other
grants or conducted fund raising
7. activities for the express purpose Yes
of providing match for this
program.
Please explain why you have or The insurance settlement will provide for the match. As this
7a. have not: was an unexpected loss of the vehicle there was not time
to make up the difference at the other match level.
8 This agency charges for EMTS Yes
services
If yes, when was the last time
8a. you reviewed your fee structure? Annually
8b If no, please explain why your
agency does not bill for services:
9. Authorized Agent
9a. Title Chairman, Board of County Commissioners
9b. First Name Barbara
9c. Last Name Kirkmeyer
9d. Daytime Phone Number 970-356-4000
9e. Date 12:00:00 AM
4
9f. Signature of Authorized Agent
Go Back
mhtml:file://C:\Documents and Settings\jvanegdom\Local Settings\Temporary Internet File... 2/14/2011
Hello