To view the description of the report including instructions please click here.
Section 1: Approved Private School Program Information (Non-Special Act School District) | ||
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(Enter 12-digit SED Code Below) |
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SCHOOL NAME
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ADDRESS (include building name, room number, or mail stop information)
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CITY
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STATE
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ZIP
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Section 2 - Approved Private School Contact Person for Information | |
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NAME/TITLE
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TELEPHONE (include Area Code)
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FAX
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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.) | ||
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(Enter 12-digit SED Code Below) |
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LOCAL EDUCATION AGENCY NAME
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ADDRESS (include building name, room number, or mail stop information)
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CITY
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STATE
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ZIP
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IMPORTANT NOTE: This form must be received by the State Education Department and by the designated LEA, by November 28, 209 Section 3: Designated Local Education Agency Information |
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(Enter 12-digit SED Code Below) |
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LOCAL EDUCATION AGENCY NAME
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ADDRESS (include building name, room number, or mail stop information)
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CITY
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STATE
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ZIP
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Section 4: Status of Designated Local Education Agency |
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A | ||
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1 | Continuation - The LEA designated for 2020-2021 was also designated for 2019-2020 | |
2 | Revision - The LEA designated for 2020-2021 is different than the LEA designated for 2019-2020 | |
3 | Initial - This is the first year in which an LEA has been designated by this approved special education program (ASEP) |
Certification and Assurances |
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The local education agency (LEA) listed in Section 3 is designated by this ASEP to be allocated additional IDEA Section 611 and Section 619 flow-through funds by the State Education Department, based on the December 1, 1998 count of students provided educational services pursuant to Article 81 of the Education Law, as reported to SED in the PD-2 report, adjusted by a population and poverty factor, for appropriate sub-allocation to this ASEP. I understand that the LEA designated in Section 3 will receive such additional IDEA funds for the 2020-2021 year, and will continue to receive IDEA allocations for subsequent years, to be sub-allocated to this school, unless a revised form is submitted to SED for the designation of another LEA for the 2020-2021 school year.
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.