DI-SE-F10
MISSISSIPPI DEPARTMENT OF EDUCATION
OFFICE OF SPECIAL EDUCATION
EDUCABLE CHILD PROGRAM
P.O. BOX 771, SUITE 301
JACKSON, MS 39205
PUBLIC SCHOOL DISTRICT APPLICATION for financial assistance when placing a student with a disability in a
private school/facility (YELLOW FORM)
SESSION 20______ - 20______
Section 1, 2 and 3 must be completed by Public School District
Application MUST BE COMPLETE (Please Type or Print)
1.
INFORMATION PERTAINING TO STUDENT
Name
_____________________________________________________________________________________________
(Last)
(First)
(Middle)
Date of
Birth____________________________________________Age__________Sex__________Race______________
(Month)
(Day)
(Year)
The above-named student resides in the___________________________________________________________
(Name of Public School District)
At this time placement in this district is not in accordance with the best educational practices and the district
recommends placement at______________________________________________________________________
(Name of Private School)
MSIS # _____________________________
DATE OF ELIGIBILITY: ________________
DATE OF IEP _______________________
IEP REVISION DATE __________________
TYPE OF DISABILITY (Circle the Child’s Disability)
1.
2.
3.
4.
5.
6.
7.
2.
Mental Retardation (Intellectual Disability)
Specific Learning Disability
Language/Speech Impaired
Hearing Impaired
Visually Impaired
Deaf-Blind
Emotional Disability
8.
9.
10.
11.
12.
13.
Other Health Impairment
Multiple Disabilities
Autism
Developmentally Delayed
Traumatic Brain Injury
Orthopedic Impairment
INFORMATION PERTAINING TO PUBLIC SCHOOL DISTRICT TO WHICH WARRANT SHOULD
BE MAILED
Name of School District__________________________________________________________________
Address_______________________________________________________________________________
(Street, Route and/or Box No.)
City_________________________________ State_______________________ Zip_________________
Phone_______________________________
Revised 08/17/2011
3.
CERTIFICATION OF PUBLIC SCHOOL DISTRICT
Application for financial assistance, as provided by Senate Bill 2620, Regular Session 1978, is hereby
made for _____________________________________________________________________________.
(Name of Student)
The educational options have been discussed with the student’s parent(s) and written parental permission
for placement at the school named in Section 4 is on file in this school district.
Other financial assistance provided for this child’s tuition is as follows [Name the various sources of
payment (i.e., SSI, welfare, insurance, scholarships) as well as the amount of financial assistance from each
source]:
SOURCE(S) _____________________________________ AMOUNT(S) __________________________
If financial assistance is made available, I hereby agree to:
a) Furnish the State Department of Education or its authorized agent such information as it may request
concerning the attendance of the student for whom financial assistance is requested;
b) Return such funds if the student fails to attend and to notify the State Department of Education
immediately of the date the student discontinues attendance;
c) Notify promptly the school and the State Department of Education of any change in my address or of
the student for whom financial assistance is granted by submitting a written that statement.
I hereby certify that financial assistance is requested for the sole purpose of paying tuition at a private
school/facility providing educational service to this child with a disability. I understand that if financial
assistance is sought, obtained or expended for any purpose other than that set forth in the statute and in the
regulations of the State Department of Education, I shall be liable as provided by Senate Bill 2620, regular
Session 1978 (Educable Child Program).
The information submitted in this application is true and correct to the best of my knowledge and belief. I
am aware that only claims for assistance with the approved signature and address below will be honored.
______________________________
(Date)
4.
___________________________________________
(District Superintendent’s Signature)
INFORMATION PERTAINING TO PRIVATE SCHOOL/FACILITY (To be completed by private
School/Facility)
Name of School_________________________________________________________________________
Address____________________________________________ _________________ _______ _______
(Street, Route and/or Box No.)
(City/Town)
(State)
(Zip)
I, being the Duly Authorized Official of the above-named school, certify that the above-named student has
been accepted and is in actual attendance in the school session from:
__________________ - ______________________
(Date services began) (Date school session ends)
School Program: _________________________
(Total number of session days)
Tuition cost for this period of time $__________.
I certify that the above-named school is a private school/facility meeting all requirements of the Mississippi
Department of Education in which the institution is located to provide educational services for children
with disabilities. I understand that both an eligibility ruling and meeting to develop an Individualized
Educational Program for this student must have taken place before any financial assistance may be
obtained. This student’s Determination of Eligibility Report, Assessment Team Report and Individualized
Education Program are attached.
________Psychiatric Day Treatment
________Intermediate Care Facility for the Mentally Retarded (ICF-MR)
________Psychiatric Residential Treatment Facility (PRTF)
_________________________
(Date)
Revised 08/17/2011
_________________________________________
(Signature and Title of Private School Official)
DI-SE-F10a
August 2011
Justification for Placement
Name of Child _______________________________ Date of Birth _______________
1.
SPECIFIC reasons that the above-named student cannot be provided a FAPE in an existing or a
modified program in the ____________________________________________School District are:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Note: Please attach pertinent documentation such as psychological recommendation reports or letters.
2.
The following State-funded institutions (i.e., East MS or MS State Hospital, Hudspeth, Ellisville, North or
South MS Regional Centers) have been contracted to determine if placement would be appropriate:
________________________________
Name of Institution
_________________________________
Contact Person
_____________
Date
______________________________________________________________________________________
Results
________________________________
Name of Institution
__________________________________
Contact Person
____________
Date
______________________________________________________________________________________
Results
Has the child been placed on a waiting list? ____________________________________
__________________________________________________
Institution
3.
_______________________________
Anticipated Date of Entrance
The following nearby districts have been contacted to determine if the student could be enrolled there:
__________________________________
District Contacted
_________________________________
Contact Person
_____________
Date
______________________________________________________________________________________
Results
__________________________________
District Contacted
_________________________________
Contact Person
_____________
Date
______________________________________________________________________________________
Results
4.
The following funding sources (such as SSI and Medicaid) have been explored to assist with funding:
______________________________________________________________________________________
______________________________________________________________________________________
Revised 08/17/2011
5.
The District is aware that if it does make an out-of-district placement consistent with State regulations, the
district must pay $8000 of the total cost of the placement. The remainder of the total cost will be paid from
Part B set-aside funds, as available. If State monies are not sufficient to fund all applications, there will be a
ratable reduction for all recipients.
6.
Did the IEP Committee address other options when determining placement? Please explain.
a.
Modification of existing programs
______________________________________________________________________________________
______________________________________________________________________________________
b.
Additional support aids and services
______________________________________________________________________________________
______________________________________________________________________________________
c.
Other options explored
______________________________________________________________________________________
______________________________________________________________________________________
7.
Did the IEP Committee consider the Least Restrictive Environment for this child, i.e., the student being
educated with students having no disabilities to the maximum extent appropriate and the participation in
nonacademic and extracurricular services and activities? Please explain.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
__________________________________________________
Signature of School District Superintendent
__________________________________________________
Date
Revised 08/17/2011
MISSISSIPPI DEPARTMENT OF EDUCATION
OFFICE OF SPECIAL EDUCATION
EDUCABLE CHILD PROGRAM
P.O. BOX 771, SUITE 301
JACKSON, MISSISSIPPI 39205
Procedures For Public School Districts To Follow When Placing A Student with A Disability In
A Private School/Facility
1.
The Individual Education Program (IEP) Committee determined that a Free Appropriate
Public Education (FAPE) in the least restrictive environment cannot be provided for the
student with a disability in the local district (Justification for Placement, DI-SE-F10a).
2.
The IEP Committee, after discussion with the student’s parents, decided that the
appropriate educational placement for this student is in a private school/facility.
3.
Appropriate school district personnel checked to see if the suggested private
school/facility is approved by the Educable Child Program, MS Department of Education
MDE), Office of Special Education (OSE). The MS Department of Education will not
provide Educable Child funds for any medical services; therefore, any obligation made
by school district personnel to pay for such services will be at school district expense.
4.
The local school district will initiate and conduct meetings to develop or review/revise
the IEP of each student placed in a private school. An IEP will be developed by the local
school district before placing the student in the private school. The student’s teacher or
other representative from the private school will be in attendance at the meeting. If a
representative from the private school cannot be present at the meeting, participation by
the private school will be provided through individual or conference calls, or written
communication. The local school district has the final responsibility for the development
of the IEP for each student it places in a private school; however, after the initial
placement, the local school district has the option to delegate this responsibility to the
private school. Even then, the local school district shall ensure that IEP meetings are
conducted in accordance with the following steps: i.e., written prior notice will be given
to parents, receipt will be verified, parents and a school district representative will be at
the meeting, be involved in any decision about the IEP, and agree to proposed changes
before they are implemented. On the IEP, please specify the name of the private
school/facility and the special education and related services to be provided. No financial
aid will be provided until the child has been ruled eligible and an IEP has been
appropriately developed.
5.
Appropriate school district personnel are to complete the following:
a) Check to see if the student’s teacher at the private school/facility is certified in the
area of the student’s eligibility ruling. Make sure the student’s eligibility ruling
Determination of Eligibility Report (DER) is current;
Revised 08/17/2011
b) Complete Sections 1, 2 and 3 of (Application Form) DI-SE-F10. Section 4 must be
completed by the private school/facility;
c) Send the following forms and reports to the MS Department of Education, Office of
Special Education, Attention: Program Coordinator, Educable Child Program;
1) Public School District Application for Financial Assistance When Placing A
Student with a Disability in A Private School/Facility (DI-SE-F10);
2) Determination of Eligibility Report (DER);
3) Evaluation Report (ER);
4) Individualized Educational Program (IEP);
5) Justification for Placement (DI-SE-F10a).
All eligibilities (initial and reevaluations) must be obtained from the district in which the
student resides. Eligibilities from facilities will not be accepted.
NOTE: Faxed copies are not acceptable.
6.
The student may be placed in the private school/facility as soon as an eligibility ruling
has been obtained and an individualized educational plan has been developed. IF A
STUDENT IS PLACED BEFORE FINAL APPROVAL HAS BEEN OBTAINED BY
THE MS DEPARTMENT OF EDUCATION, THE SCHOOL DISTRICT MUST BE
PREPARED TO ACCEPT FULL RESPONSIBILITY OF PAYING ANY EXPENSES
THAT ARE DISALLOWED BY THE MS DEPARTMENT OF EDUCATION. The
district is responsible for paying the first $8,000 of the total tuition cost. The remainder of
the total cost will be paid from Part B set-aside funds, as available. If State monies are
not sufficient to fund all applications, there will be ratable reduction for all recipients.
Following full review of the application, Determination of Eligibility Report, and
Individualized Educational Plan, the school district will be notified in writing by the MS
Department of Education as to the approval of the student for reimbursement under this
program. Applications are to be submitted to the OSE within fifteen (15) days from
the student’s date of enrollment. Applications submitted after fifteen days of
enrollment/admission may result in delay of payment. Deadline dates for applying for
financial assistance are as follows:





FIRST PAY PERIOD (Beginning of school through September): Due August 31st ,
and September 14th
SECOND PAY PERIOD (October through November): Due November 10th
THIRD PAY PERIOD (December through January): Due January 13th
FOURTH PAY PERIOD (February through March): Due March 12th
FIFTH PAY PERIOD (April through last day of school): Due May 17th & May 31st
NOTE:

Revised 08/17/2011
If an approved student’s name was not included on an Educable Child
Reimbursement Form or was not paid on a particular pay period, please submit
the approved student’s name and any requested information on an Educable
Child Reimbursement Form for that pay period.

All incomplete applications for the FIRST PAY PERIOD and the SECOND PAY
PERIOD must be returned to the Educable Child Program no later than
JANUARY 13th in order to receive funding for those periods. No exceptions.

All incomplete applications for the THIRD PAY PERIOD and the FOURTH
PAY PERIOD must be returned to the Educable Child Program no later than PAY
PERIOD must be returned to the Educable Child Program no later than APRIL
27th in order to receive funding for those periods. No exceptions.

If required documentation is not received by the Mississippi Department of
Education by these due dates, reimbursement for those pay periods will not be
made and payment will be the District’s responsibility.
7.
If a student is withdrawn from a private facility and no longer receives services
from the private facility, an official drop form must be completed and submitted to
the Office of Special Education, MS Department of Education, Attention: Program
Coordinator, Educable Child Program within seven (7) working days.
8.
If the School District transfers the student to a different facility, a drop form must
be completed and submitted to the Office of Special Education, MS Department of
Education, Attention: Program Coordinator, Educable Child Program within seven
(7) working days. A new application is required.
9.
If a student is discharged from a facility and is readmitted at a later date, a new
student application with the required documents is required.
10.
No Educable Child funds are appropriated for services provided through the summer
months.
11.
A current DER and IEP must be on file in the Office of Special Education, Educable
Child program at all times. It is the responsibility of the school district to send
documentation throughout the school year. Funding will be held if the student
application/file is not current.
12.
Financial assistance will be based on 180 regular school days.
13.
In order to receive a payment for educational funds of approved students enrolled in the
Educable Child Program, the following forms must be completed and submitted to the
Office of Special Education, MS Department of Education:
a) Educable Child Reimbursement Form;
b) A copy of the roll book or attendance report to substantiate the days present; and
c) A copy of the invoice from the facility for each approved student.
NOTE: Faxed copies or emails are not acceptable.
Revised 08/17/2011
14.
The Office of Special Education will mail a report listing the names of the approved
students and the amounts paid to the school district after the Electronic Payment Transfer
for each pay period has been submitted to the Office of Accounting. The information will
not be reviewed via telephone or provided via email or fax.
15.
School Districts’ role in Department of Human Services placement of students with
disabilities in Private Facilities:
a) School Districts must participate in the IEP meeting for those students whose
residency is within their school district and the IEP must be completed on the
school district’s form.
b) All eligibilities (initial and reevaluations) must be completed by the school
district of residency and documented on the school district of residency’s form.
Revised 08/17/2011