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it TEXAS I ep.ulrncnl ,, NMI, If,..IIIh Department of State Health Services FORM A: FACE PAGE Proposal for Financial Assistance RFP# EMS/LPG - 0328.1 This form requests basic information about the respondent and project, including the signature of the authorized representative. The face pace is the cover paoe of the proposal and must be completed in its entiretv. A. Public Health Region : RESPONDENT INFORMATION B. Trauma Service Area : 1) LEGAL BUSINESS NAME: 1A) DBA 2) MAILING Address Information (include mailing address, street, city, county, state and zip code): Check if address change ? 3) PAYEE Name and Mailing Address (if different from above): Check if address change ? 4) Federal Tax ID No. (9 digit), State of Texas Comptroller Vendor ID No. (14 digit) or Social Security Number (9 digit) : *The respondent acknowledges, understands and agrees that the respondent's choice to use a social security number as the vendor identification number for the contract, may result in the social security number being made public via state open records requests. 5) TYPE OF ENTITY (check all that apply): ? City ? Nonprofit Organization* ? Individual ? County ? For Profit Organization* ? Private ? Other Political Subdivision ? Registered First Responder Org ? State Controlled Institution of Higher Learning ? State Agency ? Community-Based Organization ? Hospital ? Licensed EMS Provider ? Minority Organization ? EMS Education Facility ? Injury Prevention Organization ? Other (specify): *If incor orated, provide 10-digit charter number assi ned b Secreta of State: 6) PROPOSED BUDGET PERIOD: Start Date: October 1, 2009 End Date: August 31, 2010 7 COUNTIES SERVED BY PROJECT: 8A) PROPOSED PROJECT includes: (check all that apply) ? Ambulance ? Monitor/Defibrillator ? EMS Equipment 8B) Number of entities represented in proposal: ? Injury Prevention ? EMS Training/Education 8C AMOUNT OF FUNDING REQUESTED: 10) PROJECT CONTACT PERSON 9) PROJECTED EXPENDITURES Name: Does respondent's projected state or federal expenditures exceed Phone: $500,000 for respondent's current fiscal year (excluding amount Fax: requested in line 8 above)? ** E-mail: Yes El No E] 11) FINANCIAL OFFICER Name: **Projected expenditures should include funding for all activities including Phone: pass through" federal funds from all state agencies and non project-related Fax: DSHS funds. E-mail: The facts affirmed by me in this proposal are truthful and I warrant the respondent is in compliance with the assurances and certifications contained in APPENDIX A: DSHS Assurances and Certifications. I understand the truthfulness of the facts affirmed herein and the continuing compliance with these requirements are conditions precedent to the award of a contract. This document has been duly authorized by the governing body of the respondent and I (the person signing below) am authorized to represent the respondent. 12) AUTHORIZED REPRESENTATIVE Check if change ? 13) SIGNATURE OF AUTHORIZED REPRESENTATIVE Name: Title: Phone: 14) DATE Fax: E-mail: Page 27 RFP# EMS/LPG - 0328.1