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FORM F: ORGANIZATION STATEMENT OF FINANCIAL RESOURCES <br />Instructions: All respondents must answer all questions on this page to qualify for <br />consideration of funding. If not applicable, state "N/A". Attach additional sheets, if needed. <br />Failure to complete this form will result in respondent being ineligible for LPG funding. <br />Note: DSHS prohibits the use of grant funds to supplant (reducing of applicant budget upon receipt of <br />grant) currently budgeted funds. (Funds being removed from your budget not including matching funds) <br />Grant History: List all DSHS Local Projects Grant funds received in last five years. <br />Year Project(s) Amount <br />Requested Amount <br />Received Amount <br />Utilized <br /> <br /> <br /> <br /> <br /> <br />1. Has your organization been established for one year or more? ? YES ? NO <br />2. If your organization receives this grant, will your service have money removed from <br />your operating or capital budget that will offset this award (other than matching <br />funds ? **Note: Checking "yes" to this question will result in applicant being <br />ineligible for LPG funding. Before answering this question, see definition of <br />"supplant" in Section I Introduction, Definitions** ? YES ? NO <br />3. What are your current liquid assets in dollars? (estimated savings, investments, operating budget) <br />4. What is your outstanding debt in dollars? <br />5. What are your current accounts receivables in dollars? <br />6. What is your source of matching funds for equipment or supply requests in this proposal? You must indicate <br />source(s) if matching funds are required, see Section II, E. Program Requirements. <br />7. Complete the following if you are a pre-hospital service organization. <br />a. What is your average number of calls per month per vehicle? <br />b. What percent of calls are emergency? <br />8. Do you bill for services? ? YES ? NO <br />a. If yes, what is the charge for emergency 911 calls? <br />b. If yes, what is the charge for non-emergency transports? <br />9. What is your current billing collection rate <br />In dollars per year? <br />Page 35 RFP# EMS/LPG - 0328.1