::�[ r;i1;���,�;;�;�s�1-:�::�:�:::::�c�t--------- ----....... -------··-·------- ---- ----------·-"·--··

Fire)- Background check Batteries (EMS) ' chargers Tuition for classes not I Hydrants available through AFA, approved as certifiable by AFA

I Lodging at government rate Pay for Mileage rather than fuel costs. Will pay at government rate Meals at Federal per diem rate, meals with overnight stay only

--·------------- ---� - -- -- ---·----· ---------

UNALLOWABLE EXPENDITURES

The following items were determined to be Lmallowable expenditure items by the Arkansas Fire Protection Serviees Board on June 281

\ 2012: This list is not all inclu�ivc. UNALLOW ABLE EXPENDITURES

Animals Interest only payments Penalties Late Fees Bank Charges Cell Phones Checks

Contractual or Professional Services Office Supplies Station Maintenance Storage Sheds Uniforms Rental fees

Ambulances Web Pages Monthly rental fees on heating foel storage tanks Monthly monitoring for security systems Fuel for PO V's, Chiefs vehicles, "runaround" . T ' • '

This list does not include all allowable and unallowable expenditures for Act 833. It provides a general idea. If you have any questions, you may contact:

Larry Brewer Kendell Snyder

Arkansas Fire Protection Services Board ADEM-Oflice of Fire Services

(501) 328-7204 (501) 683-6781

Funding and Response Capability Survev

This is not required for certification; however we are asking that each department fill out this section in order to compile a working list of fire department cun-ent capabilities and funding sources

11

Version 12-2ll-2016

OFFICE OF FIRE PROTECTION SERVICES

2017 CERTIFICATION APPLICATION

DATE NF!RS ID# ____ _

DEPARTMENT NAME ------------ PHYSICAL ADDRESS ----- ---------

COUNTY _ _____ _ CITY ---------ZIP ___ _ FD PHONE L__L_ _____ _

FDFAX L__L_ ____ _ EMAIL _________ _ CTO NAME ________ ___ _

TYPE OF DEPARTMENT: RURAL Non-Profit( ) Improvement District ( ) FIRE DISTRICT ( MUNICIPAL (

CLASSIFICATION OF DEPARTMENT: VOLUNTEER ( COMBINATION ( PAID ON CALL ( PAID I

TOTAL NUMBER OF PERSONNEL __ _ TOTAL NUMBER OF ACTIVE FIREFIGHTING PERSONNEL (ACT 808 - 2009) __ _

FIRE CHIEF NAME ____________ _ MAILING ADDRESS ______________ _

COUNTY -------- CITY --------- ZIP HM PHONE'---'-------

WK PHONE'---''-------- CELL PHONE'----'------- EMAIL __________ _

.L�MENT: SC[)A Units Minimum 4 & spa:ire SCBA Bottles (1 perSCBA- Minimum 4) Meets NFPA 15001/1971-2007. Yes ( No ( p_;.B_S_Q_��L PRQJ£_glVE EQUIPMEN! (PPE): Requires full set for ;,ii a�tive p,orsonnel meeting NFPA 1500 #1971-2007. Yes ( No ( TRAININ� & T!lAINING RECOB,Q_�; Active Firefighters Completed (16) Hrs of Certified Training & Training Records Maintained for All Personnel. [Certified Training must meet (Act 808 .. 2009) to qualify for 2017 Funds & completed tr.iining for the 2016CalendarYear [Jan 1- Dec 31, 2016]. Yes { No I WORKERS COMPS...NSATION: (Rural Departments Only) Personnel List on file Current with County Clerk. Yes ( No (

REQUEST I�'OR FUNDS (Rural Departments ONLY) Total Amount Requested: ,'l ____ ,

>'" Firefighting Training:

).-- Firefighting Equipment

Y Capital Expenditure:

Fire Chief County Fire Service Coordinator

- -- --- ---- -- -·

·----- ,, _________ -

County Judge or Mayor

IMPQBJANT NOTICE: the entitles involved above, certifies by signing this document that all Provisions of Act 833 as amended, including all implementation Procedures from Department of Finance and Administration, Office of Flre Protection Services, & the Arkansas Department of Emergency Management wlll be strictly followed.

Office of Fire Protection Services C/0 Arkansas Department of Emergency Management Building #9501- Camp Joseph T. Robinson

North Little Rock, AR 72199-9600

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=1RE DEPARTMENT/DISTRICT:

:ONTACT PERSON:

': MAIL

DEPARTMENT OF FINANCE AND ADMINISTRATION - FIRE PROTECTION SERVICES PROGRAM ACT 833 OF 1991, AS AMENDED - FORM DFA-FP-7A

2016 ANNUAL EXPENDITURE REPORT

COUNTY:

DAYTIME PHONE NUMBER

fYPE OF DEPARTMENT/REPORT PERIOD MUNICIPAL

=uNDS RECEIVED DURING PERIOD:

RURAL. __ _ REPORTING PERIOD 2016 CALENDAR YEAR

AMOUNT

$

$

$

$

Redistribution $

FUNDS RECEIVED DURING 2016 PERIOD $

FUNDS CARRIED FORWARD FROM PREVIOUS YEARS s

(Do not report bank balance - only unspent Act 833 funds)

TOTAL FUNDS RECEIVED AND CARRIED FORWARD(1)

/iO/DAY/YR

FUNDS EXPENDED DURING PERIOD (CALENDAR YEAR 2016)

ITEMS ALLOCATED TO PURCHASE IN THE FUTURE (USE ONLY IF YOU HAVE UNSPENT ACT 833 FUNDS)

ITEM COST

s

$

$

$

$

s

$

$

$

(2) TOTAL FUNDS SPENT $

ITEM

$

$

$

s

$

$

$

$

TOTAL 833 FUNDS TO ALLOCATE:

SUBTRACT (2) FROM (1) FOR BAL OF S 833 FUNDS TO ALLOCATE:

COST

-------

'ire DepartmenVDistrict Signature/ Title

:aunty Fire Service Coordinator �equired for Rural Volunteer Fire Department Signature/ Title

luorum Court/Chief Executive Officer :county Judge/Mayor) Signature/ Title

JEW FOR 2017-IF carry forward/ Allocated Funds exist, you must submit a bank statement or fund balance sheet for December 2016 or anuary 2017 showing the account balance**

13

Date

Date

Date