Rules for Missouri Ambulance Districts

I. Background and Formation

Formation of ADs

The purpose of ambulance districts (ADs) in Missouri is to “establish and maintain an ambulance service ... and to acquire for, develop, expand, extend and improve such service.” (190.060.1[1]).

An AD does not have to be entirely joined or contiguous; however, for any territory that is noncontiguous, at least a portion of that territory must lie within five miles of the AD. An AD may include all or part of a county or counties, and it can include incorporated cities within its boundaries. But two ADs cannot overlap territories. Except for ADs whose formation was petitioned for by contiguous St. Louis County fire protection districts (190.015.2), new ADs cannot exist in St. Louis or Jackson counties because those counties’ populations each exceed 400,000. Existing ADs may continue to operate, however, even if the population of the county grows to exceed 400,000 inhabitants (190.010.1). There is a special exception to allow formation of an AD when formed as a pairing with a fire protection district  (190.010.2).

The law permitting formation of ADs resulted from citizens wanting a higher level of service than volunteers, the fire service, hospitals, cities, counties, or nonprofit associations could provide. Some ADs in Missouri began as nonprofit associations before becoming political subdivisions of the state. Nonprofit associations and political subdivisions operate under different rules. Changing from a nonprofit ambulance district to formation of an AD requires changes in the mode of governance and can be an organizational challenge.

Nonprofit associations usually make their own rules following the Nonprofit Corporation Law (355). Meetings may be open or closed, purchases follow whatever rules the association has established, and many legal requirements for an AD generally do not apply.

An AD, unlike a nonprofit association, must comply with all the generic state statutes that apply to political subdivisions or municipal corporations. Unlike a nonprofit association, membership in an AD is mandatory, not voluntary. Every person within its boundaries becomes a member. Also, ADs may do only what the Missouri Revised Statutes (RSMo) specifically permit and may not do things the statutes forbid.

Categories and accountabilities

It is important to understand the uniqueness of ADs and the difference between an AD and other governments, such as a city or county, and between an AD and an ambulance department of another government. The latter is a dependent entity, which is accountable to the political subdivision of which it is a part. The rules for a dependent entity are largely determined by the political subdivision and not statutes. Because of different governing statutes, a meeting of the AD board of directors  is sometimes run differently from a Board of Aldermen or Village Trustees.

Independent or Special Purpose Entities

Are political subdivisions

Dependent Entities

Accountable to a political subdivision


Sovereignty means the AD has supreme, independent authority and power to rule and make law over a geographical area. Historically, sovereignty was connected to a government’s ability to guarantee the best interests of its own citizens. Therefore, an AD is typically not beholden to a city or county. Questions of intergovernmental regulation are complex, and legal counsel should be consulted when another entity (like a city or county) attempts to impose its regulations on an AD. These situations can often trigger political disputes as well, so discussion between the governing boards is advisable always.

Formation procedures

An AD in Missouri is established by a petition signed by voters living within the proposed AD boundaries. The term “voter” always means a registered voter (1.035 and 116.010.6). Signatures must equal at least 10% of the votes cast in the last election for governor. (190.015.1). Alternatively, a contiguous group of St. Louis county fire protection district boards of directors can initiate the formation of an AD, but only for emergency ambulance services (190.015.2).

A petition for an AD must be filed with the county clerk and must have at least six parts:

  1. A description of the territory in the proposed AD;
  2. The names of any cities or villages within the proposed AD;
  3. The name of the proposed AD, i.e., “to be known as ________ Ambulance District”;
  4. An estimate of the proposed AD’s population, so that the petition can state that the population of the proposed AD is not less than 2,000;
  5. An assessed valuation of the proposed AD, so that the petition can state that the assessed valuation is not less than $10 million;
  6. A request for the question of establishing and maintaining an ambulance service be submitted to the voters within the proposed AD.

For a more detailed explanation of the process of forming an AD, go to the Missouri Association of Ambulance Districts and click on “information to help you get started.”

If the proposed AD is in St. Louis County, the petition must include an additional statement on whether the AD will be funded by a property or a sales tax.

If the proposed boundaries cross county lines, the petition must be filed in the county having the largest percentage of area. Because every question put before the AD’s voters will have to appear on both the majority and minority county ballots, it is good to establish positive relations with all counties involved at an early stage.

By law (190.020.3), the petitioners must pay in advance for publication or posting notices of a public hearing, and the public notices must include a description of the territory in the proposed AD. Consult with the county clerk to find out the expected fee to accompany the petition. Fortunately the petitioners have to be reimbursed by the AD if the AD is formed.

After the filing, the county clerk must present the petition for the proposed AD to the county commission, who in turn must set a public hearing on the proposed AD within 30 to 40 days after the filing (190.015.1, 190.020.1). The public notices for the hearing must be published or posted no less than 20 days before the public hearing (190.020.2).

The law says (190.025) if there are competing AD formation petitions for part of the same area, a single public hearing must be held for all competing petitions. At the public hearing, the petitioners who filed first may amend their petition to include any part of the territory in the subsequent petitions; however, the focus for the remainder of the public hearing will be only the first petition. Subsequent petitions are then on hold until termination of proceedings on the first petition or a subsequent petition is dismissed or withdrawn by its petitioners.


The county commissions may ask the AD petitioners for reimbursement for the public notice of election.

At the hearing, the county commission finds whether the facts of the petition meet or do not meet the requirements of becoming an AD. If requirements are met, the county commission submits the question to the voters for their consent (190.030). If requirements are not met, the matter is terminated and the county commission considers any subsequent petitions on hold (190.025).

The law requires a public notice of election and contents of the notice (190.035); however, the law does not specify who is responsible and pays for publishing the election notice. Costs of holding an election for a special district must be deposited with the election authority in advance of the election. (115.077)

Election requirement

Ballot of Proposed AD
  • Shall the AD be incorporated?
  • Shall the AD have authority to levy a tax of 30 cents per $100 of assessed value or impose a 0.5% sales tax?

Even when the county commission finds that the facts of the petition meet the requirements, the AD is not created until voters in the proposed AD consent to the creation in an election. If voters approve creation of the AD, the directors of the first AD will be decided by a separate, follow up election (190.050.1; 190.050.2).

Once the election authority certifies the results, by law (190.045), the county commission files certified copies of the election results with the county clerks in each county where part of the proposed AD lies. If the proposed AD is approved by a majority of the voters, then the county commission orders the AD organized.

Although not in the law, copies of the county commission order organizing the AD should be filed with the recorder of deeds in each county in which the AD has territory.

Election Authority
  • County clerk in most cases
  • Board of election commissioners in a few
  • large counties and cities
  • Secretary of State (SoS) for state-wide elections


After an AD has been declared organized, the law says the declaring county commission must divide the newly organized AD into six election districts as equal in population as possible — numbering each election district from one to six by lots, for example, by drawing numbers from a hat (190.050.1).

After each decennial census, the county commission that declared the AD established must reapportion the districts to maintain the balance of representation on the board. (190.050.1)

The same law also states that within 90 days after an AD has been declared organized, the declaring county commission must hold an election for AD directors. Voters in each AD election district will vote only for the director who will represent their AD election district. There is no voting for at “at-large” directors except in ADs in qualifying class two counties; although, currently no ADs qualify for “at-large” directors.

Filing Closing Date

The county commission may set a candidate filing closing date other than the one in 115.127.5 (190.050.3).

AD board members serve three-year terms. However, to stagger terms so that all board members will not be up for election simultaneously, special rules apply to the first board (190.050.1). For the first AD board, the members from election districts three and six serve three years, the members from election districts two and five serve two years, and the members from election districts one and four serve one year.

Elections are held every year. After the first set of terms is completed, board members serve three-year terms except in cases of resignation or disqualification. If an AD qualifies for “at-large” directors, other special rules apply to that AD’s first board (190.050.2).

ADs are political subdivisions in which certain persons are prohibited from holding office. For information on these exceptions, see Chapter Ill. Officials and Board Operations and Chapter XVIII. Elections.

First Board Meeting

The first meeting of the first AD board of directors must be held within 30 days after the election of the initial directors at a time and place designated by the declaring county commission (190.055.1).

Checks and balances

Ambulance District Checks and Balances

Judicial Branch
State court system

  • Circuit
  • Appeals
  • Supreme

Legislative Branch
AD Board of Directors

  • Chair
  • Directors
  • Officers
  • Advisers

Executive Branch
EMS Chief

  • EMTs
  • Paramedics

By high school, everyone should have learned that the American model of government contains three branches: judicial, legislative and executive. Each branch of government has “checks and balances” over the other branches, which by design, means that a certain amount of healthy friction is a part of the system.

An AD does not have its own judicial branch, but uses the state system of circuit, appeals and supreme courts. An AD’s legislative branch is its board of directors — the congress of the AD, so to speak. The officers of the board are part of the legislative branch.

The AD board of directors elects one of its own to chair the board. The AD board will also hire an Emergency Medical Services (EMS) chief (EC) to head the executive branch on a day-to-day basis. Emergency medical technicians (EMTs) and paramedics are part of the executive branch. For information on the chair, see Chapter Ill. Officials and Board Operations. For more Information on the EMS chief, see Chapter XII. Personnel.

County classifications

The four county classifications are determined by law (48.020). Knowing the classification of the county (or, counties) in which an AD is located is important because some AD laws are written specfic to a county classification. For instance, a law might say a requirement applies to “any AD located in a first class county.”