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TEXAS t>a? u" %IW Department of State Health Services FORM A: FACE PAGE - Proposal for Financial Assistance RFPWEMSAP"278.1 This form requests basic information about the respondent and project, including the signature of the authorized representative. 7be face page is the coverpage of the poposat and must be completed in its endrely. 1) LEGAL NAME: City of San Marcos 1A) DRA: San Marcos Park Ranger Div. 139 2) MAILING Address Information (include mailing address, street, city, county, state and zip code): Check If address change ? City of San Marcos 630 East Ho kins Street, San Marcos, Texas 78666 3) PAYEE Mailing Address (if different from above): Check if address change ? 4) Federal Tax 10 No. (9 digit), State of Texas Comptroller Vendor ID No. (14 digit) or Social 74.6002238 Security Number (9 digit) : 7h*vsndbrwJ=wradyas,andarsdendsxdaprWdWftwxWtchokemmessoddsecurrrynwterasftwmbrldfwdgtaEiwnumberfwdwca*wtnWin tin era sodak a rAw rands ub& v6 sdrle records 5) TYPE OF ENTITY (check all that apply): ® City ? Hospital ? State Controlled Institution of Higher Learning ? County ? Registered First Responder ? Minority Organization ? Other Political Subdivision ? Injury Prevention Organization ? HUB Certified ? State Agency ? Regional Advisory Council ? Faith Based (Nonprofit Org) ? Indian Tribe ? Nonprofit Organization* ? Private ? Licensed EMS Provider ? For Profit Organization* ? Individual ? EMS Educational Fadlity ? Community-Based Organization ? Other (specify): *If i rated, rovide 10-d' it charter number assigned b Sw ate of State: 6) PROPOSED BUDGET PERIOD: Start Date: October 1, 2008 End Date: August 31, 2009 7) COUNTIES SERVED BY PROJECT: City of San Marcos, Hays County 8) AMOUNT OF FUNDING REQUESTED: $20,238.14 10) PROJECT CONTACT PERSON 9) PROJECTED EXPENDITURES Does respondent's projected state or federal expenditures exceed $500,000 Name: Richard Salmon for respondent's current fiscal year (excluding amount requested in line 8 Phone: (512) 393-8405 above)?" 1} Yes ? No Fax: (512) 353-7273 **Projected expenditures should include funding for all activities including 'pass E-mail: Salmon,Richard@ci.san-marcos.tx.us through" federal funds from all slate agencies and non project-related DSHS funds. . 9A Number of entities resented in ro I: "I 11) FINANCIAL OFFICER 98) PROPOSED PROJECT Includes: (Check all that apply) ® EMS Equipment Name: Ismael Garcia ? Ambulance Phone: (512),393-8178 ? Injury Prevention Fax: (512) 392-4612 TraningkEdurxtion E-mail: Garcia Ismael@ci.san-marcos.tx.us Monitor/Defibrillator The facts affirmed by me in this proposal are tnrthful and I warrant that the respondent is in oDmplianoe with the assurances and certifications contained in APPENDIX A: DSKS Anurances and Gerd icatims. I understand that the hOfulness 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 respondent and I (the person signing below) am authorized to represent the respondent 12) AUTHORIZED REPRESENTATIVE Check ff change ? 13) SIG OF H D REPRESENTATIVE Name: Rick Menchaca 14) DATE Title: City Manager Fax: (512) 3964656 E-mail: Menchaca_,Rick@d son-marcos.bLus Phone: (512) 393-8100 May 12, 200B