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					                                        VERMONT DEPARTMENT OF EDUCATION

            SPECIAL EDUCATION EXPENDITURE REPORT FOR FY-2011
                                                    Information Sheet


   Supervisory Name Union:                                                            SU Number:
   A. Reporting Entities
   The following list shows the reporting entities that will submit a separate Special Education Expenditure Report for FY-
   2011. The list includes the supervisory union as well as all of its member school districts (including town, joint
   contract, interstate, and union school districts) that directly pay any special education cost. All school districts which
   receive either a Block or an EEE Grant must be listed below and submit reports.
   Reporting Entities:




   B. Contact Person
   The contact person at the supervisory union who can answer questions about the Special Education Expenditure
   Reports for FY-2011 is:
              Name:                                                    Phone #:
               Title:                                           E-mail Address:
   The contact person at the supervisory union who can answer questions about Worksheet A is:

              Name:                                                    Phone #:
               Title:                                           E-mail Address:

   C. Personnel to Receive Financial Information
   Any information sent to this supervisory union regarding the Special Education Expenditure Reports should be sent to
   the two (and only two) individuals below. The information will include explanations of how the formula
   reimbursement is calculated, printouts showing the calculation of reimbursement for the school districts within the
   supervisory union, and information on problems with the reports themselves.
              Name:                                                        Name:
                Title:                                                       Title:
   Mailing Address:                                            Mailing Address:




                         (Signature of Superintendent)                                                (Date)

          SUBMIT TO THE SPECIAL EDUCATION FINANCE UNIT BY OCTOBER 1, 2010

Special Education Expenditure Report for FY-2011 - Information Sheet                                                 Page 1
                                                                            VERMONT DEPARTMENT OF EDUCATION

WORKSHEET C
                                                                           RESIDENTIAL COST DETAIL


FY-2011 cumulative through 6/30/11 (Submit for all reporting entities - but only with final reports.)
Reporting Entity: ____________________________
SU No.: __________                                                                                                                                                                    Page No.__

For each student who was residentially placed during the year (July 1, 2010 to June 30, 2011), list the student and placement information. Also list the costs incurred for that student's special
education program for the period of the placement. If a student was placed in more than one placement or if the student exited then returned to the residential placement, list each residential
stay on a separate line. Only include residential placements that the reporting entity paid for; do not include residential placements for State-Placed students paid directly by State agencies.

                     Student Information                                   Placement Information                       Cost Breakdown for Student's Residential Placement
                              Date      Disability Student's         Name of     Date Entered Last Day in           Special                    Other                                     TOTAL
 Student's    Student ID    of Birth     Category   Town            Residential   Residential Residential          Education    Equipment   Instruction    Related      Transpor-         COST
  Initials     Number     (mm/dd/yy) (01-14)         Code            School        for Year      for Year           Tuition                    Costs       Services       tation

1.                                                                                                                                                                                              0.00
2.                                                                                                                                                                                              0.00
3.                                                                                                                                                                                              0.00
4.                                                                                                                                                                                              0.00
5.                                                                                                                                                                                              0.00
6.                                                                                                                                                                                              0.00
7.                                                                                                                                                                                              0.00
8.                                                                                                                                                                                              0.00
9.                                                                                                                                                                                              0.00
10.                                                                                                                                                                                             0.00
11.                                                                                                                                                                                             0.00
12.                                                                                                                                                                                             0.00
13.                                                                                                                                                                                             0.00
14.                                                                                                                                                                                             0.00
15.                                                                                                                                                                                             0.00
16.                                                                                                                                                                                             0.00

      Total Cost for FY-2011 Special Education Residential Placements Paid by Reporting Entity                           0.00        0.00          0.00         0.00          0.00              0.00

Special Education Expenditure Report for FY-2011 - Worksheet C
                                                                             VERMONT DEPARTMENT OF EDUCATION

WORKSHEET B
                                                                         EXTRAORDINARY COST DETAIL
FY-2011 cumulative through: _________/_________/_________
Reporting Entity: _____________________________________                            Use one line for each student.
Supervisory Union Number: _______                                                  Do not list students until their total cost exceeds $50,000.                 Page No.______

                          Student Information                                                  Cost Breakdown for Student**
                            Date      Disability   Student's   Residential       Special                  Other                                     TOTAL           Less      Eligible
 Student's   Student ID    of Birth   Category      Town       Placement?       Education   Equipment Instruction      Related         Transpor-     COST           Base    Extraordinary
 Initials*    Number       (mm/dd/yy)  (01-14)       Code      (Yes or No)       Tuition                  Costs        Services          tation                     Cost        Cost
 1.                                                                                                                                                          0.00 -50,000             0.00
 2.                                                                                                                                                          0.00 -50,000             0.00
 3.                                                                                                                                                          0.00 -50,000             0.00
 4.                                                                                                                                                          0.00 -50,000             0.00
 5.                                                                                                                                                          0.00 -50,000             0.00
 6.                                                                                                                                                          0.00 -50,000             0.00
 7.                                                                                                                                                          0.00 -50,000             0.00
 8.                                                                                                                                                          0.00 -50,000             0.00
 9.                                                                                                                                                          0.00 -50,000             0.00
10.                                                                                                                                                          0.00 -50,000             0.00
* Students are only eligible from their 3rd birthday up to their 22nd birthday while on an IEP.                         TOTAL ELIGIBLE EXTRAORDINARY COST 2                           0.00
    Only include cost of paid from Federal funds or State EEE grant and grant and only for that the student is eligible.
** Do not include costs IEP services not paid from federal funds or EEEonly for the period the period the student is eligible.
    This amount is to be entered on Page 1 in the total column. Show the cost cost for students in the eligible column and and for preschool students preschool column.
2 This amount is to be entered on Page 1 in the total column. Then show thefor K-12 K-12 students in the eligible columnfor preschool students in thein the preschool column.

DISTRIBUTION OF EXTRAORDINARY COST TO SCHOOL DISTRICTS:
(For use by Supervisory Unions, Joint Contract Districts, and Interstate School Districts with Extraordinary Cost.)
                                            Name of                                 School District's Share
      LEA Code                          School District                              of Extraordinary Cost




   Total Eligible Extraordinary Cost (must equal total in box 2 above)                         0.00


  Special Education Expenditure Report for FY-2011 - Worksheet B
                                                                                                 VERMONT DEPARTMENT OF EDUCATION

WORKSHEET A
                                                           Billing of Special Education Costs for State-Placed Students

FY-2011 cumulative through: 2/28/2011                       Use this form only for the February report.                                                                                   Page No. _____
Reporting Entity: ____________________________                                                                                                                                                                  Please provide your best estimate
Supervisory Union Number: ___________                                                                                                                                                                       of the cost for this item to be paid
List students in alphabetical order by last name; list student's first and last name. List each service for each student on a separate line. Show actual beginning and ending date that each service        in FY-2011 by this school district.
was provided.
Line                            Date of       Student ID     Public School                    Description of Service**                 Attachment?       Dates of Service:            Cost of Eligible    ESTIMATED FY-2011 Cost of
No.      Student's Name*         Birth         Number           Attended              (Refer to Instructions for Service Descriptions)  Yes   No Beginning Date:     End Date:       Spec. Ed. Services*** Eligible Spec. Ed. Services

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
                                                                                                                                                                                      1
                                    Total Special Education Cost Eligible for State-Placed Students Reimbursement                                                                                      $0.00                           $0.00
*      Enter first and last name but ONLY include students placed by the State in a school district in which neither parent resides or as defined in 16 VSA § 11 (28).
** Refer to the instructions for the most common services and their definitions. For other categories, enter a description of the service required by the IEP. If additional information is needed for a
service, it should be included here.
*** The costs excluded from State reimbursement are all costs paid from federal funds.
   1 Enter this amount in the Total Column on Page 1 and the appropriate breakdown of the total in the "K-12 Eligible", "K-12 Ineligible" and Pre-School" columns.

      Special Education Expenditure Report for FY-2011 - Worksheet A (February 28th version)
                                                                               VERMONT DEPARTMENT OF EDUCATION

WORKSHEET A
                                                         Billing of Special Education Costs for State-Placed Students

FY-2011 cumulative through: ______/______/______             Use this form for all reports except the February report.
Reporting Entity: ____________________________
Supervisory Union Number: ___________                                                                                                                                     Page No. _____
List students in alphabetical order by last name; list student's first and last name. List each service for each student on a separate line. Show actual beginning and ending date that each
service was provided.
Line                            Date of      Student ID     Public School                 Description of Service**                 Attachment?      Dates of Service:       Cost of Eligible
No.      Student's Name*         Birth        Number          Attended            (Refer to Instructions for Service Descriptions)  Yes   No Beginning Date:    End Date:  Spec. Ed. Services***

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
                                                                                                                                                                           1
                                        Total Special Education Cost Eligible for State-Placed Students Reimbursement                                                                       $0.00
*         Enter first and last name but ONLY include students placed by the State in a school district in which neither parent resides or as defined in 16 VSA § 11 (28).
** Refer to the instructions for the common services and their definitions. For other categories, enter a description of the service required by the IEP. If additional information is needed for
a service, it should be included here.
*** The costs excluded from State reimbursement are all costs paid from federal funds.
      1
          Enter this amount in the Total Column on Page 1 and the appropriate breakdown of the total in the "K-12 Eligible", "K-12 Ineligible" and Pre-School" columns.

           Special Education Expenditure Report for FY-2011 - Worksheet A
                                          VERMONT DEPARTMENT OF EDUCATION


SPECIAL EDUCATION EXPENDITURE REPORT FOR FY-2011
Page 2


DISTRIBUTION TO SCHOOL DISTRICTS OF AMOUNTS ON TOTAL NET COST LINE OF PAGE 1 IN THE "ELIGIBLE
K-12" AND "PRE-SCHOOL" COLUMNS:

                                                                                  Eligible K-12            Pre-School
  LEA Code                         Name of School District                           Amount                 Amount




                                                                             3                      3
                  TOTAL                                                                            0.00               0.00
3 The totals here for the "Eligible K-12" and "Pre-School" must agree exactly with the amounts shown on the TOTAL NET
COST line for the "Eligible K-12" and "Pre-School" columns on Page 1.




  Special Education Expenditure Report for FY-2011 - Page 2
                                                      VERMONT DEPARTMENT OF EDUCATION

                            SPECIAL EDUCATION EXPENDITURE REPORT FOR FY-2011
FY-2011 cumulative through ______/______/______
Reporting Entity: _____________________________
SU No.: _____                                                                    TOTAL               K-12 Special Education Cost             Pre-School
                                                                                SPECIAL                 (Excludes Pre-School)                  Special
PART I                                                                         EDUCATION               Eligible        Ineligible            Education
 1000 DIRECT INSTRUCTION SERVICES
        100 Personnel Services-Salaries                                                     0.00
        200 Personnel Services - Employee Benefits                                          0.00
        300 Purchased Professional & Technical Services                                     0.00
        400 Purchased Property Services                                                     0.00
        500 Other Purchased Services                                                        0.00
        600 Supplies                                                                        0.00
        700 Property                                                                        0.00
        800 Other Objects                                                                   0.00
        900 Other Uses of Funds                                                             0.00
 2100 SUPPORT SERVICES-STUDENTS
      100-900 (EXCEPT 700 reported below)                                                   0.00
        700 Equipment                                                                       0.00
 2200 SUPPORT SERVICES -Instructional Staff                                                 0.00
 2300 SUPPORT SERVICES -General Administration                                              0.00
 2400 SUPPORT SERVICES -School/Area Administration                                          0.00
 2500 CENTRAL SERVICES                                                                      0.00
 2600 OPERATION/MAINTENANCE OF PLANT SERVICES                                               0.00
 2700 STUDENT TRANSPORTATION SERVICES                                                       0.00
 2900 OTHER SUPPORTING SERVICES                                                             0.00
 3000 COMMUNITY SERVICES                                                                    0.00
 4000 FACILITIES ACQUISITION & CONSTRUCTION                                                 0.00
 5000 OTHER USES                                                                            0.00
Non-special education costs charged to Sped grants                                          0.00
TOTAL SPECIAL EDUCATION EXPENDITURES                                                        0.00                 0.00              0.00                 0.00
PART II
EXPENDITURES CHARGED TO FEDERAL GRANTS:
          IDEA-B Basic Flow Through (4226-01)                                      0.00
          IDEA-B Pre-School Flow Through (4228-01)                                 0.00
          Infants & Toddlers (4235)                                                0.00
         IDEA-B Basic ARRA Funds (4756-01)                                         0.00
         IDEA-B PreSchool ARRA Funds (4758-01)                                     0.00
         Grant Award #:                                                            0.00
         Grant Award #:                                                            0.00
EXPENDITURES CHARGED TO STATE FUNDS AND MATCH:
          Mainstream Block Grant (3201)                                            0.00
          Local Block Grant Match                                                  0.00
          State-Placed Student Cost (Worksheet A)                    1             0.00
          Extraordinary Cost (Worksheet B)                           2             0.00
          Essential Early Education Grant (3204)                                   0.00
         Grant Award #:                                                            0.00
         Grant Award #:                                                            0.00
EXPENDITURES CHARGED TO OTHER REVENUE:
          Special Education Tuition from other LEA's                               0.00
          Excess Costs from other LEA's                                            0.00
ASSESSMENT PAID TO S.U. OR UNION SCHOOLS                                           0.00 .
TOTAL GRANT EXPENDITURES & OTHER EXCLUSIONS                                        0.00               0.00            0.00                              0.00
TOTAL NET COST (Total Part 1 less Total Part II)                                   0.00  3            0.00            0.00 3                            0.00
I certify under the penalty of perjury that the information contained in this report and the attached worksheets is correct.
Signed: ___________________________________________                                                  Date: ___________
1 Report here the TOTAL COST from Worksheet A.                                  2 Report here the Total Eligible Extraordinary Cost from Worksheet B.
3 The amounts from the Eligible and Pre-School columns must be distributed to SCHOOL DISTRICTS on Page 2.


   Special Education Expenditure Report for FY-2011 - Page 1

				
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