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APPROVED SPECIAL EDUCATION PROGRAM REQUEST FOR §4410(b) VENDOR FUNDING
FOR 2024-2025 SCHOOL YEAR

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

The following types of schools may use this form to request §4410(b) vendor funding from school districts that have Committee on Preschool Special Education (CPSE) or Committee on Special Education (CSE) responsibility for students with disabilities. The use of this form is not mandatory, and schools may develop and use their own form for requesting §4410(b) vendor funding.

Instructions:

  1. Send a completed form, with original signature, to each local education agency (LEA) from which §4410(b) vendor funding for the 2024-2025 school year is requested. NYSED recommends that this form be sent to each LEA by November 24, 2023; however, a subsequent date may be established by each LEA.
  2. There is no need to submit a copy of this form to the State Education Department.
  3. Submit a list of the names of students comprising the counts reported in Section 3, Tables A and B, to the LEA with the form. This list must be marked “confidential.”
  4. Retain one copy and any supporting documentation in your school for reference and audit purposes.  The required retention period ends on June 30, 2033.
  5. If you have any questions about §4410(b) funding, please email your questions to datasupport@nysed.gov.
Section 1: Approved Special Education Program Requesting §4410(b) 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: NYSED recommends that LEAs receive this form by November 24, 2023, or the subsequent date established by the LEA, in order to provide accurate §4410(b) vendor funding to approved special education programs for the 2024-2025 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 for Students Residing in LEA Identified in Section 2.
Report the count of students with disabilities ages 3-5 in part A and the count of students with disabilities ages 6-21 in part B.
Age, enrollment, and type of service provided are as of October 4, 2023.
A Students with disabilities ages 3-5
Age, enrollment, and type of service provided are as of October 4, 2023
Each student should be included only once in category 1, 2, or 3
Count of SWDs Ages 3-21* Count of SWDs Ages 3-5 *
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 Ages 3-5 and Ages 3-21
B Students with disabilities ages 6-21
Age and enrollment are as of October 4, 2023
Count of SWDs
Ages 6-21
1 Count of students with disabilities, ages 6-21  

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 as of October 4, 2023. I certify that students placed in this school were served in a manner consistent with their respective Individualized Education Programs. A list 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: October 4, 2023