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APPROVED SPECIAL EDUCATION PROGRAM REQUEST FOR IDEA VENDOR FUNDING
FOR 2013-2014 SCHOOL YEAR

To view the description of the report including instructions please click here.

Section 1:  Approved Special Education Program Requesting Vendor Funding
(Enter 12-digit SED Code Below)
Blank Boxes for SED Code
SCHOOL NAME

 

ADDRESS (include building name, room number, or mail stop information)

 


 

CITY

 

STATE

 

ZIP

 


Contact Person of Approved Special Education Program Requesting Vendor Funding
NAME/TITLE

 

TELEPHONE (include Area Code)

 

FAX

 


IMPORTANT NOTE: The LEA must receive this form by November 26, 2012, in order to provide accurate vendor funding of IDEA funds to approved special education programs for the 2013-2014 school year.

Section 2: Local Education Agency (LEA) Requested to Issue Vendor Funding. (For students placed in out-of-State schools by the courts or State agencies, the LEA is the school district in which the student resided at the time of such placement.)
(Enter 12-digit SED Code Below)
Blank Boxes for SED Code
LOCAL EDUCATION AGENCY NAME

 

ADDRESS (include building name, room number, or mail stop information)

 


 

CITY

 

STATE

 

ZIP

 


Section 3: Child Counts, Pursuant to IDEA Sections 611 and 619, for Students Residing in LEA who is identified in Section 2.
Students with disabilities, ages 3-5, on October 3, 2012 (please determine enrollment, age, and type of service as of October 3, 2012.
A Students with disabilities, ages 3-4, on October 3, 2012 (please determine enrollment, age, and type of service provided as of October 3, 2012). Each student should be counted only once in either Line 1, 2 or 3. Count
§611*
Count
§619*
1 Number of preschool students (ages 3-4) provided related services only. Do not report students in this line if they are also receiving other preschool special education programs.    
2 Number of preschool students (ages 3-4) provided a preschool special education program, which includes Special Education Itinerant Teacher (SEIT) services and/or full or part-time special class or special class in an integrated setting services. These students may also be receiving related services.  Please note that if students receive services from more than one provider, only the provider that is designated as the "coordinating provider" may report the student on this form.    
3 Count of school-age students (ages 4-5) attending programs for school-age children.    
*Note: Students who are ages 3-5 are eligible to be counted under both Section 611 and Section 619
B Students with disabilities, ages 6-21, on October 3, 2012
(please determine enrollment and age as of October 3, 2012).
Count
§611
Count
§619
1 Count of students with disabilities, ages 6-21   NA

*IDEA Section 619 flow-through funds are directed to students with disabilities, ages 3-5. Section 611 flow-through funds are directed to students with disabilities, ages 3-21.

Certification and Assurances

I have reviewed the information reported in this form and certify that this is a complete and accurate count of students with disabilities who were placed in this program by the local education agency listed in Section 2 of this form, on October 3, 2012. I certify that such students placed in this school were served in a manner consistent with their respective Individualized Education Programs. A listing of the names of the students reported in Section 3 will be submitted to the local education agency with this form and marked “confidential”.

Form must be signed and dated by Chief School Administrative Officer. Please print out a printer friendly version of this form in Word or PDF.

Last Updated: November 25, 2013