NORTH DAKOTA RURAL EMS ASSISTANCE FUND GRANT APPLICATION (PART II) NORTH DAKOTA DEPARTMENT OF HEALTH DIVISION OF EMERGENCY MEDICAL SYSTEMS SFN 61298 (9-2017)

Legal Entity/Service

Mailing Address

City

Physical Address

ZIP Code

Contact Person/Representative

City ZIP Code

Daytime Telephone Number

Email Address

Date of Application

This completed application form and any accompanying documents must be submitted to the Department of Health postmarked no later than 5 p.m. on October 27, 2017. You may attach additional pages if necessary. Applications submitted after the deadline, sent by facsimile (fax), submitted in handwriting, or otherwise not in accordance with the application's instructions WILL NOT be accepted or considered for funding. Please refer to the accompanying "North Dakota Rural EMS Assistance Fund Grant Guidance - Part II" for further detailed instructions for application completion. This grant guidance document is designed to assist you through the completion of this application and additional documents to assure eligibility.

Federal Tax ID#

Funding Area Number Total Amount Requested

Name of Service Big Picture Updated

(Personnel Roster, Vehicle Roster,

and General Information)

WebCUR Information Up-to-date

Checklist of Required Documentation: (Required from each ambulance service in the Funding Area)Financial

Information Form Included

SFN 61298 (9-2017) Page 2 of 10

Criticality of the Ambulance Service (Pass or Fail) Refer to the North Dakota Rural EMS Assistance Fund Grant Guidance - Part II (page 5) for detailed information regarding the completion of this section.

SFN 61298 (9-2017) Page 3 of 10

Financial Need (15 Points) Refer to the North Dakota Rural EMS Assistance Fund Grant Guidance - Part II (page 4) for detailed information regarding the completion of this section.

Financial Information Form

Funding Area Number

Ambulance Service

1. Please enter fiscal year end date

$Cash in Bank

$3. Unpaid Accounts Receivable Invoiced/Billed Within 12 Month Period

$Other Financial Assets

$2. Total Value of Cash in Bank and Other Financial Assets

Bill Date of Bill Amount Owed

$5. Accounts Payable

Do you own or rent your building(s)? Own Rent

$If you own your buildings, what is the value of the building(s)?

List those bills that are 30 days past due

N/A

4. Equipment

Vehicle Year Vehicle Cost Cost of Equipment Added to Vehicle Mileage

SFN 61298 (9-2017) Page 4 of 10

6. List of outstanding loans

Purpose of Loan Payoff Amount Monthly Payment Number of Remaining Payments Loan End Date

List those bills that are 30 days past due (continued)

Bill Date of Bill Amount Owed

7. Annual Revenue

$Ambulance Service Fees

$Donations/Fundraisers

$Grants

$Mill Levy

$Interest Income

$All Other Income

$ Total Annual Revenue

8. Annual Expenses

$Permanent Staffing

$Volunteer Staffing

$Tax Based Revenue

Payroll Taxes 1 $

SFN 61298 (9-2017) Page 5 of 10

8. Expenses (continued)

$Interest Expense

$Office Supplies

$Repairs

$Insurance 3

$Legal & Other Professional Fees

$Fuel

$Facility Rent Expense

$Utilities 4

$Medical Supplies

$Bad Debt Expense 5

All Other Expenses (Please List)

$

$Telephone

Billing Service Fees 2

9. Have you foregone any expenses because of funding shortages? (please list)

1.

2.

3.

$ Total Annual Operating Expenses

$ Revenues Less Expenses

$

$

$

$

$

$

$

$

SFN 61298 (9-2017) Page 6 of 10

EMS System Integration Development and Justification (Pass or Fail) Refer to the North Dakota Rural EMS Assistance Fund Grant Guidance - Part II (page 5) for detailed information regarding the completion of this section.

SFN 61298 (9-2017) Page 7 of 10

Strategic Planning (20 Points) Refer to the North Dakota Rural EMS Assistance Fund Grant Guidance - Part II (page 6) for detailed information regarding the completion of this section.

SFN 61298 (9-2017) Page 8 of 10

Quality Improvement (20 Points) Refer to the North Dakota Rural EMS Assistance Fund Grant Guidance - Part II (page 6) for detailed information regarding the completion of this section.

Project Budget Itemization Refer to the North Dakota Rural EMS Assistance Fund Grant Guidance - Part II (page 6) for detailed information regarding the completion of this section.

Personnel/Staffing

Travel, Food and Lodging

Supplies

Rent/Utilities

Communications (Telephone/Postage)

SFN 61298 (9-2017) Page 9 of 10

Equipment

Consultant/Contractual

Other/Optional

Other/Optional

Other/Optional

Other/Optional

Other/Optional

Project Budget Justification Using budgeted numbers, briefly describe in detail how monies will be spent in each category of the proposed budget.

Other/Optional

Signature of Squad Leader

The name of service and signature of an authorized representative (squad leader / board chair) of each involved entity/service is required in order for this application to be considered complete. Signature in this block verifies agreement of all arrangements/project efforts established in this grant application.

Name of Squad Date

DateName of SquadSignature of Squad Leader

DateName of SquadSignature of Squad Leader

DateName of SquadSignature of Squad Leader

Signature Block

SFN 61298 (9-2017) Page 10 of 10

Refusal Signature Block

As the person completing this application, I certify that the information contained within is true and correct to the best of my knowledge. I also acknowledge that any funds received from this grant will be expended according to the laws of the State of North Dakota for the purpose stated in this application.

Signature of Authorized Representative Date

Signature of Authorized Representative

Signature of Squad Leader

The name of service and signature of an authorized representative (squad leader / board chair) of each entity/service refusing to participate in grant planning is required in order for this application to be considered complete. Signature in this block verifies that each entity/service has been given the opportunity to participate in this grant planning and has willingly opted out. Run volume for entities/services not participating will not be taken into consideration for funding awards.

Name of Squad Date

DateName of SquadSignature of Squad Leader

DateName of SquadSignature of Squad Leader

Submit completed application and accompanying documents to:

North Dakota Department of Health Division of Emergency Medical Systems 1720 Burlington Drive Bismarck, ND 58504

All applications must be postmarked no later than 5 p.m. on October 27, 2017. Any applications received after this

deadline will not be accepted. A confirmation e-mail will be sent upon receipt of this application.