Special Education

Statement of Assurance for
Out-of-State Residential or Emergency Interim Placement

Statement of Assurance - Out-of-State Residential or Emergency Interim Placement PDF PDF document(74 KB)

Student Name:

 

DOB:

 

Application Instructions for State Aid Reimbursement of Tuition Costs

In an application seeking State reimbursement for a student in an approved out-of-State residential school or emergency interim placement, the CSE must submit the following documentation to NYSED for review and approval against the criteria established for approval of State reimbursement pursuant to section 200.6(j) of the Regulations of the Commissioner of Education.  

  1. CSE cover letter that describes the reasons for submitting the application.
  2. Application checklist
  3. Certification by the CSE that the student is of school age; has a disability or combination of disabilities; has a current individualized education program (IEP); and that the nature or severity of the student’s disability is such that appropriate public facilities for instruction are not available.
  4. Documentation that no appropriate public or private facilities for instruction are available within New York State [8 NYCRR 200.6(j)] and for emergency interim placements, documentation that no appropriate approved in-State or out-of-State program is available.  The listing of approved in-State and out-of-State private schools appropriate to the student’s disability can be obtained at http://www.p12.nysed.gov/specialed/privateschools/home.html.  Include copies of all acceptance or rejection letters.
  5. Student profile.
  6. Paper copy of the Office of Special Education preapproval data (OSES/DOSES) form.  This serves as confirmation that the CSE filed an electronic Assurance of Required Evaluations for Private School Reimbursement with NYSED within six business days of the recommendation by the CSE that the student requires placement in an approved private school, or for reapplications, prior to June 1st of the year preceding the school year for which funding is sought.  The application for reimbursement containing the required documentation can be located and completed on the NYSED/STAC website at: http://www.oms.nysed.gov/stac.
  7. Signed STAC-1 (summer, if applicable, and school year; see website in item (e) to access STAC-1 form).
  8. For an application for State reimbursement of a student in a residential program, including an emergency interim placement, a proposed plan and timetable for enabling the student to return to a less restrictive environment or a statement of reasons why such a plan is currently not appropriate.

Within 15 business days of receipt of an application for State reimbursement, NYSED will notify the CSE of an initial denial of State reimbursements.  School districts will receive, by fax, a signed STAC-1 indicating approval of State reimbursement.  It is the district’s responsibility to forward a copy of the NYSED approved STAC-1 to the approved private school.

I hereby certify the following:

  1. For an initial application to an approved private school, the CSE has provided a current individual evaluation or reevaluation of the student.  The  individual evaluation and the classroom observation, where applicable, and any other evaluations necessary to describe the relevant circumstances leading up to the recommendation and the basis for the recommendation for change of placement have been completed within six months prior to the CSE’s initial recommendation for private school placement.
  2. The CSE has a current IEP for the student.
  3. The CSE has certified that the student is of school age and has a disability or combination of disabilities, and has further documented that the nature or severity of the student's disability is such that appropriate public facilities for instruction are not available.  The documentation reviewed by the CSE, establishing the nature and severity of the disability and warranting placement of the student in an approved private school, is maintained in the student’s education records and is available for review by NYSED.
  4. The following documentation submitted with this application is true and accurate.
    1. Documentation of efforts to place the student in a public facility and the outcomes of those efforts, and/or of CSE findings regarding the lack of suitability of each currently available and geographically accessible public placement;
    2. Documentation of all efforts to enable the student to benefit from instruction in less restrictive settings using support services and supplementary aids and special education services as set forth in subdivisions (d), (e) and (f) below, and/or for those services not used, a statement of reasons why such services were not recommended;
    3. Documentation that residential services are necessary to meet the student's educational needs as identified in the student's IEP, including a proposed plan and timetable for enabling the student to return to a less restrictive environment or a statement of reasons why such a plan is not currently appropriate;
    4. In the case of a recommendation by the CSE for placement of a student in an educational facility outside of the State, documentation that there are no appropriate public or private facilities for instruction available within this State; and
    5. In the case of a reapplication for State reimbursement of tuition costs, documentation of the continuing need for placement of the student in a private school.

Signature of School District Official:                         Date:                                                                                                                     

Last Updated: March 9, 2012