CCR1990134COMMON COUNCIL - CITY OF MUSKEG0
RESOLUTION #134-90
AMBULANCE SERVICE PROVIDERS REIMBURSEMENT
AUTHORIZING EXECUTION OF APPLICATION FOR
(Tess Corners Volunteer Fire Department)
WHEREAS, Nisconsin Act 102 provides supplemental funds to
ambulance services owned or operated by a volunteer fire
department, and
WHEREAS, ambulance service providers who plan to seek Act 102
funds must complete an "Application for Ambulance Service
Providers Reimbursement", and
WHEREAS, the Finance Committee has recommended approval.
NOW, THEREFORE, BE IT RESOLVED that, upon the recommendation of
the Finance Committee, the Mayor and City Clerk are hereby
authorized to sign the "Application for Ambulance Service
Providers Reimbursement", as attached, in the name of the City.
DATED THIS 2znd DAY OF May , 1990.
FINANCE COMMITTEE
Ald. Daniel J. Hilt
Ald. Edwin P. Dumke
Ald. Harold L. Sanders
ATTEST :
City Clerk
5/90
jz
.~ . . .- .. " ., . . . I. .,
,. I , .. .
1 . " .... . .I
. .~
.. ~ :, .~ .I., '' '
. -.. . :.
-, DEPARTMENT .OF"HEALTH AND SOCIAL SERVICES ; . . STATE OF WISCONSIN
'DOH 7255 (&/90) .
.' . Dlvtrtor~of. .. t+ealth/& Section Act 102,
..
. APPLICATION FOR AMBULANCE SERVICE PROVIDERS REIMBURSEMENT UNDER ACT 102
Name of Service ~~3 c e ,? F,'<e Do+,,tprovider # 60- ,c'/c:
-i
.. 1. Prlmary Serilce Area: Please attach a map s) which shows your primary service
. area(s), excluding mutual aid and b ack-up territory.
I
2. Total Population Served In Primary Sewice Area:y2 -1
? 3. Contract Servlce Area: Please attach map(s) showing the contract service area,
excluding mutual aid and backup territory.
a. Name of Contracting Agency: ~,pn c r= ~o/ K',-+ ~xpif
b. Address of Contracting Agency: W/VV 36 73/ ir,~~Y C-ro r: rJ D u
&ufkE,C/, _. /<J, 7 J-3 /J -d
Y
c. Designated contact person within contracting agency LLJ , ?Am
4. Total Population Sewed in Contract Sew Area:/'-
5. Type of Service: (Check one box ONLY)
i~ co~nty Indian Tribe city [ J Village
JkJ Volunteer Fire Department U Nonstock, nonprofit corporation IJ (pursuant to Chapter 181, Wis. Stats.)
6. By my SI nature,'I certfy that the precedln Information Is true to the best of my knowledge and belief. I furtter certwthat supplemental fu 2 s recehred by the ambulance service named above will not be used to replace or decrease exlstln funds and that a report will be flled every 2 years with the DHSS beglnnlng Jul 1,1992, detaing expenditure of these program funds in conformity with 1989 Wisconsin ~ct 102.