Docstoc

Applicaiton---Missouri-Department-of-Elementary-and-Secondary-

Document Sample
Applicaiton---Missouri-Department-of-Elementary-and-Secondary- Powered By Docstoc
					THE MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION Division of Special Education - Funds Management Section FY08 HIGH NEED FUND APPLICATION July 1, 2007 - June 30, 2008 Due Date: January 31 2009 DISTRICT INFORMATION
School District Name: Test District Address: Test Address District Contact: Shelley Witherbee
3x Current Exp per ADA

County District Code: Phone Number: Email Address: $ 22,785.12
DESE REVISED DATE

000-100 573-751-4385 shelley.witherbee@dese.mo.gov 7,595.04 8/20/2008

Enter the Current Expenditure per Average Daily Attendance (ADA) amount from the Annual Secretary of the Board Report (ASBR)

$

SUBMISSION INSTRUCTIONS
The High Need Fund reimburses special education expenditures required to implement a student's IEP, which exceed three times the current expenditure per average daily attendance as calculated on the district Annual Secretary of the Board Report for the year in which expenditures are claimed. 2007-2008 costs claimed should be itemized by the categories listed below and explained if indicated with an (*). Cooperatives may not submit applications. Districts must maintain expenditure detail for three (3) years for all students for whom High Need Fund reimbursement is being requested. Please have the Superintendent review and comply with the assurance statement, and submit the application VIA EMAIL to webreplyspefm@dese.mo.gov on or before January 31, 2009.

DISTRICTS MUST READ THE HIGH NEED FUND MANUAL BEFORE COMPLETING THE HIGH NEED FUND APPLICATION.
DIRECTIONS: Districts shall complete one application for all students eligible for the fund. Districts shall use the Current Expenditure per ADA posted on the HNF webpage. All gray shaded areas of the application will automatically calculate. Reported expenditures must be from the 2007-2008 school year. The application may be downloaded from the Funds Management website at: http://www.dese.mo.gov/divspeced/Finance/HighNeedIndex.html. There are several versions of the application; the district should choose the one that best fits depending on the number of students involved in the reimbursement request. The Superintendent must complete the Assurance Section. Instructional Costs: These costs may include, but are not limited to: Teachers, Paraprofessionals, Interpreters and others as appropriate. Examples for calculating/prorating the cost of instructional staff are shown in the manual. Related Services Costs: These costs may include, but are not limited to: Occupational Therapy, Speech Therapy, Physical Therapy, Orientation and Mobility, Braille Instruction, Counseling, ABA consulting, etc. Examples for calculating/prorating the cost of related services are shown in the manual Transportation Costs: These costs may include, but are not limited to: Bus Routes, Cabs, Contracted Transportation, and/or Parent Reimbursement. Examples for calculating/prorating the cost of transportation services are shown in the manual. Tuition/Cooperative Costs: These costs may include, but are not limited to: Tuition, Cooperative Rates, and other Out of District contractual costs. The districts should report the actual cost from the invoices received on the student. Assistive Technology Costs: These costs may include, but are not limited to: Harnesses, Braille Writer, Speech to Text Software, Computers, or any other AT device needed to implement the IEP. The districts will report the actual cost from the invoice, or prorate based on the number of students using the device. Other: This category is for all other educational costs that are associated with implementing the student’s IEP. The district must include a description in the lines provided at the end of the application for any costs reported under this category. These costs are subject to DESE approval Funding from the IDEA Risk Pool may NOT be used to support the following: o Pay legal fees, court costs, or other costs associated with a cause of action brought on behalf of a child with a disability to ensure FAPE. o Pay costs that otherwise would be reimbursed as medical assistance for a child with a disability under the State Medicaid program. FY08 HNF Application Page 1 of 5

Up to 50 Students

STUDENT INFORMATION
District Billed Medicaid for Student Mark "x" if applicable
X X X X

Student Name (Last, First)

MOSIS Student ID Number
8968119686 7790930567 4867543632 6929918016 5932939389 7104614192 2430357011 9978322183 4249791106 6973679633 9639612588 8431414928 1903021677 2412199086 2539207006 3184945227 5150744786 1167803833 8344560861 1788242106 9901606411 2471155898 7902724041 2564869629 2732429856 1049886941 1702507068 1918724156 1166817067 7249187112 3299093002 8239982859 3376502676 3947453612 6602813382

Other* Instruction
23,652.19 21,522.39 15,888.12 37,169.74 21,411.09 20,178.38

Related Services
9,210.77 4,707.95 9,021.77 9,021.77 6,917.48 2,489.23 7,211.38 5,443.07 7,972.00 4,707.95 8,137.06 7,572.00 7,572.89 5,957.60 5,957.60 1,991.38 6,627.85 4,857.85 5,838.19 7,006.73 7,942.18 15,593.97 7,942.18 7,213.07 4,857.78 5,443.07 3,450.00 6,627.85 8,256.47 6,627.85 8,256.47 1,407.85 6,627.85 8,256.47 5,838.19

Transportation
3,815.77 3,815.77 3,815.77 3,815.77 3,815.77 3,815.77 3,815.77 3,815.77 3,815.77 3,815.77 3,815.77 3,815.77 3,815.77 3,815.77

Tuition

Assistive Technology

Describe Below

DESE USE ONLY Total Educational Costs
36,678.73 30,046.11 28,725.66 50,007.28 32,144.34 26,483.38 35,554.59 28,285.23 33,198.86 30,046.11 34,332.69 26,255.17 32,135.86 53,692.05 26,747.84 29,803.64 26,863.68 29,778.00 26,325.25

DESE USE ONLY Amount Requested after 3x
13,893.61 7,260.99 5,940.54 27,222.16 9,359.22 3,698.26 12,769.47 5,500.11 10,413.74 7,260.99 11,547.57 3,470.05 9,350.74 30,906.93 3,962.72 7,018.52 4,078.56 6,992.88 3,540.13 12,947.98 19,448.39 29,099.42 12,553.20 4,381.84 5,317.48 5,500.11 2,368.77 16,100.60 28,292.71 8,843.72 20,956.51 5,684.03 8,843.72 20,956.51 7,852.93

Line Number

1 Alghalith, Sami 2 Ames, Micheal 3 Baker, Keagen 4 Bartz, Austin 5 Bass, Cody 6 Bassett, Jarryd 7 Clark, Seth 8 Clayborn, Ryan 9 Colegrove, Allison 10 Cox, Nathan 11 Creason, Cody 12 Darling, Elizabeth 13 Davis, Jed 14 Eagen, John 15 Ferry, Carmen 16 Fortenberry, Tyler 17 Griffel, Cody 18 Homor, Max 19 Krammer, Grace 20 Laudwig, Jaxon 21 Lindley-Harker, Rowan 22 Mc Vay, Dalton 23 McColum, Issac 24 McCormick, Sean 25 McFarland, Austin 26 McFarland, Coy 27 Mountain, Jacob 28 Page, James 29 Pike, Ethan 30 Radmanesh, Cyrus 31 Robinson, Corey 32 Rodriguez, Calvin 33 Seavy, Phillip 34 Seavy, Richlene 35 Thompson, Dominic

01/19/97 05/30/98 11/29/95 01/17/97 08/25/94 12/11/91 02/02/90 06/19/98 05/06/94 04/30/99 03/23/00 09/16/90 07/10/95 09/01/00 09/16/00 08/24/89 11/06/89 09/22/90 08/27/98 10/23/97 07/17/01 07/11/97 05/14/01 05/25/96 08/04/88 05/23/98 08/29/95 05/28/86 03/14/01 03/07/92 12/13/00 02/05/91 04/24/92 02/02/01 04/26/00

DOB MM/DD/YY

X X

24,527.44 19,026.39 21,411.09 21,522.39

X X X

22,379.86 14,867.40 24,562.97 43,918.68 16,974.47 27,812.26

X X X

20,235.83 24,920.15 20,487.06 24,910.60 33,794.30 31,474.80 26,899.11 15,888.12

3,815.77 497.03 4,815.77 497.03 3,815.77 3,815.77 3,815.77 3,815.77 3,815.77 3,815.77 3,815.77 3,815.77 3,815.77 3,815.77 3,815.77 497.03 250.00

35,733.10 42,233.51 51,884.54 35,338.32 27,166.96 28,102.60 28,285.23 25,153.89 38,885.72 51,077.83 31,628.84 43,741.63 28,469.15 31,628.84 43,741.63 30,638.05

X

23,244.82 19,026.39 17,888.12

X X X X X

28,442.10 39,005.59 21,185.22 31,669.39 23,245.53 21,185.22 31,669.39 20,487.06

FY08 HNF Application Page 2 of 5

Up to 50 Students

Student Name (Last, First)

MOSIS Student ID Number
2191202926 8578847059 6634402302

District Billed Medicaid for Student Mark "x" if applicable
X

Other* Instruction
22,379.64 46,943.48 45,556.12

Related Services
8,137.06 5,443.07 5,443.07

Transportation
3,815.77 3,815.77

Tuition

Assistive Technology

Describe Below

DESE USE ONLY Total Educational Costs
34,332.47 56,202.32 50,999.19 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

DESE USE ONLY Amount Requested after 3x
11,547.35 33,417.20 28,214.07 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Line Number

36 Ultsch, Aaron 37 West, Brandon 38 Zeller, Patrick 39 40 41 42 43 44 45 46 47 48 49 50

12/10/99 05/15/97 03/30/96

DOB MM/DD/YY

TOTALS

19

967,362.90

251,586.97

111,657.33

0.00

0.00

1,741.09

1,332,348.29
Medicaid Funds

466,513.73
$203,581.59

OTHER* Please give brief description of any educational costs in the OTHER category. Student Name (Last, First) OR Corresponding Line Number from above. Description 21 23 24 25 35 SH Consult SH Consult Assistive Technology Evaluation Due Process Lawyer * DELETED - LITIGATION / ATTORNEY FEES NOT ALLOWED SH Consult

FY08 HNF Application Page 3 of 5

Up to 50 Students

Assurance Statement Check Box

By typing in the Superintendent's name, the Superintendent assures that the expenditures listed herein have been made solely on behalf of these students and that they are accurate to the best of his/her knowledge. Documentation must be maintained in the district for 3 years after the reimbursement date.The district is subject to fiscal monitoring on a yearly basis of all documentation used to support the expenditures reported on the HNF application.

Type Superintendent Name: Shelley Witherbee

Date:

8/20/2008

FY08 HNF Application Page 4 of 5

Up to 50 Students

Eagen, John Ferry, Carmen

2412199086 2539207006

09/01/00 09/16/00 05/14/01 07/17/01 12/13/00 02/02/01 03/14/01 12/06/00 03/23/00 08/27/98 04/26/00 12/10/99 11/29/98 10/23/97 04/30/99 05/30/98 06/19/98 01/19/97 07/11/97 05/15/97 03/30/96 01/17/97 11/29/95 05/25/96 08/29/95 08/25/94 07/10/95 05/06/94 09/16/90 12/11/91 09/22/90 03/07/92 04/24/92 02/05/91 02/02/90 10/28/89 08/24/89 11/06/89 08/04/87 08/04/88 05/28/86 07/20/88 08/11/88 06/16/86 05/23/98

McColum, Issac 7902724041 Lindley-Harker, Rowan 9901606411 Robinson, Corey 3299093002 Seavy, Richlene 3947453612 Pike, Ethan Creason, Cody 1166817067 9639612588 Van Vleck, Ethan7738693312 Krammer, Grace 8344560861 Thompson, Dominic 6602813382 Ultsch, Aaron 2191202926 Abramowitz, Jaxom 9455733919 Laudwig, Jaxon 1788242106 Cox, Nathan Ames, Micheal 6973679633 7790930567

Clayborn, Ryan 9978322183 Alghalith, Sami 8968119686 Mc Vay, Dalton 2471155898 West, Brandon Zeller, Patrick Bartz, Austin Baker, Keagen 8578847059 6634402302 6929918016 4867543632

McCormick, Sean2564869629 Mountain, Jacob 1702507068 Bass, Cody Davis, Jed 5932939389 1903021677

Colegrove, Allison 249791106 4 Darling, Elizabeth 8431414928 Bassett, Jarryd Homor, Max Seavy, Phillip Clark, Seth Conyers, Cory Griffel, Cody 7104614192 1167803833 3376502676 2430357011 8458460998 5150744786

Radmanesh, Cyrus 249187112 7 Rodriguez, Calvin 8239982859

Fortenberry, Tyler3184945227 Harris, Spenser 2313005569 McFarland, Austin 732429856 2 Page, James Reed, Sara Walck, Valerie 1918724156 2360011901 4784967338

Wachter, Thomas2516365403 McFarland, Coy 1049886941


				
DOCUMENT INFO
Shared By:
Tags: Appli, caito
Stats:
views:11
posted:11/28/2009
language:English
pages:5
Description: Applicaiton---Missouri-Department-of-Elementary-and-Secondary-