Department of Early Education and Care
DISABILITIES/SPECIAL NEEDS FLEXIBLE FUNDING BUDGET REQUEST
Child Name
Provider Name
Please Check Off/Enter: Income Eligible
Voucher
Contracted Income Eligible
Program Type________________ Voucher Service Need Code of Child: __________ Contracted Slot Number___________ or Flex Pool Slot___________
(I, T, I-T, PS or SA)
Income Eligible Contracted and Voucher Providers requesting flexible pool funding for a child with special needs must submit this form. Contracted providers and CCR&Rs approved
for funding will need to submit their approval letter from EEC, this budget form and a separate Payment Voucher (PV) reflecting the maximum monthly total reimbursable amount
calculated on page 2 of this form. Costs for any services not provided or equipment not purchased according to the request must be noted and deducted from this amount.
I. TRAINING
Provider of
Training
Description of Training
Cost of Training (Specific Unit Cost and Number of Units in Budget
Period
Total Amount
I. SUBTOTAL
II.
SPECIALIZED EQUIPMENT (Capital budget items are not allowed. Furnishings and equipment must be moveable.)
Description of Equipment and Usage
Number of Units and Unit Cost
Total Amount
II. SUBTOTAL
Page 1 of 2
IESpecialNeedsFlexPoolBudget11/27/12
Department of Early Education and Care
DISABILITIES/SPECIAL NEEDS FLEXIBLE FUNDING BUDGET REQUEST
III: AIDE POSITION REQUEST Name of staff: _______________________ Proposed Start Date: ________ End Date: ________ Proposed Hourly Rate: _______
Months: Enter per request period:
Maximum 6 months or to end of fiscal year
whichever is shorter
A) Enter Number of Full and/or Part Days
(Minus Holidays and Closures) X Hours
per day (max. 8 hrs. or less) per mo. =
Total Hours Please show calculation:
B) School Age programs please be specific:
e.g. 4 FT days X 8 hrs = 32 hrs
3 PT days X 4 hrs.
= 12 hrs
12 AS days X 3 hrs.
= 36 hrs Total
Hours: 80
III. SUBTOTAL: Proposed Hourly Rate X
Total Amount
Budget Period
Total
Hours:____
$
Total
Hours:____
Total
Hours:____
Total
Hours:____
Total
Hours:____
Total
Hours:____
Total
Hours:_____
$
$
$
$
$
$
Total Hours= Reimbursement Request
TOTAL (Add Subtotals I, II, and III)
$
__________________________________________________________________________________________
SECTION BELOW TO BE COMPLETED BY EEC/CCR&R
APPROVED START DATE: _______________________ END DATE: ______________________
TOTAL AMOUNT APPROVED: ________________________________________
SIGNATURE of Authorizing Agent: ______________________________________
Page 2 of 2
Date Approved: ______________________
IESpecialNeedsFlexPoolBudget11/27/12