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%W <br />4 <br />FORM I: FUNDING REQUEST BUDGET PAGE <br />All respondents must complete this budget page to detail the use of funds requested. Refer to Section ll, F. for funding preferences and <br />limits. <br />'You may Indicate the importance of your items by placing a priority number by each item (see Examples below). On Form H: Work Plan, <br />explain how you determined your priority. Refer to Form G: Work Plan Guidelines, 4. Budget <br />Use additional pages as needed. <br />If submitting a multiple entity proposal, submit a separate page for each entity for which funds are requested. <br />Name of enti : <br />Equipment and Supply Items: <br />Any individual item with a useful life of more than one year <br />and a cost of more than $1,000 (including shipping) requires z F- X <br />Co L-) <br />50% matching funds. Please be very descriptive when lisfing = O 0 LU <br />O Z = <br />n- Co <br />your items (9. 9. make/brand, model number, year, etc.) cr cr Co v <br />X < <3 cc z <br />cc <br /> vat ED2EL oa0CL v ixO6=L <br />Priori 1 -Welch Allen AED 10 AED 1695.00 847.50 847.50 5 4237.50 <br />Priori 1 - D na Med Deluxe Medical/02/Trauma Bag 129.99 0 129.99 8 1039.92 <br />Priori 1 - Liter Flow 02 regulator 67.95 0 67.95 8 543.60 <br />Priori 1 - D-size 02 tank 77.25 0 77.25 8 618.00 <br />Priori 1 - C-. size 02 tank 74.45 0 74.45 4 297.80 <br />Priori 1 - Nonin On II Pulse Oximeters 395.00 0 395.00 8 3160 <br />00 <br />Priority 1 - Omni-Med Bike Pack . <br /> <br />Fax machines, stereo equipment, cameras, video 199.95 0 199.95 4 799.80 <br />recorder/systems and computer/related equipment <br />(Requires a 50% match if the individual items cost exceeds <br />$500 and the useful life is greater than one year). If <br />requesting funds for computers, see Form J: Minimum <br />computer specifications form <br />Other Expenses (Education/Training, injury prevention, etc.): <br /> 10,696.62 <br />TOTAL FUNDING REQUESTED ON THIS PAGE: