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?hw <br /> <br />FORM F: ORGANIZATION STATEMENT OF FINANCIAL RESOURCES <br />Instructions: All respondents must complete the following sections. If not applicable, state "NIA„ <br />(Attach additional sheets, if needed). All si natures must be obtained and all questions must be <br />-answered to uali for consideration of funding, Note: DSHS prohibits the use of grant funds to <br />supplant (reducing of applicant budget upon receipt of grant) currently budgeted funds: (Funds being - <br />removed from your budget not including matching funds) <br />Note: Failure to complete this farm will result in respondent bein ineli ible for LPG fundin . <br />Grant Histo : List all DSHS Local Pro ects Grant funds received in last five ears. <br />Year Project(s) Amount Amount Amount <br />N A Requested Received Utilized <br />NIA <br />NIA <br />NIA <br />NIA <br />NIA <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 ? YES ® NO <br />your operating or capital budget that will offset this award (other than matching <br />funds ? "Note: Checking "yes" to this question will result Inapplicant being <br />ineli ible for LPG funding. Before answering this question, see definition of <br />"supplanting" In Section(l) Introduction, (C) Use of Funds. 2nd Daraoraoh** <br />3. What are your current fi uid assets in dollars? (estimated savings, investments, operating budget) <br />4. What is your outstanding debt in dollars? _ G <br />5. What are your current accounts receivables in dollars? #J1A <br />B. What is your source of matching funds for equipment or supply requests in this proposal? You must indicate <br />source(s) ff matching funds are required, see Section ii, E. Program Requirements. = MKwc.o <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 fear services? ? YES ® NO <br />a. If yes, what is the charge for emergency 911 calls? NIA <br />b. If yes, what is the charge for non-emergency transports? NIA <br />d. What is your current billing collection rate NIA <br />In dollars per year? NIA <br />J?% @.?ar <br />Print Name and Title <br />,. „"l .A <br />Signature <br />this Form <br />s 07- o8 <br />Date <br />Perna 17