September 2015 Exit Count Verification Form
(Form Must Be Typed or Printed)
Date_______________________
LEA Name: ______________________________________________________
LEA Number: _______________________
Number of Students with Disabilities Exiting Special education between 7/1/2014 and
6/30/2015: __________________________
Name of Authorized Exceptional Children
Personnel____________________________________
(Print)
Authorized Exceptional Children
Signature____________________________________________
Mail Child Count Verification Form To
EC Delivery Team
Exceptional Children Division
6356 Mail Service Center
Raleigh, NC 27699-6356
EXCEPTIONAL CHILDREN DIVISION
William Hussey, Director | bill.hussey@dpi.nc.gov
6356 Mail Service Center, Raleigh, North Carolina 27699-6356 | (919) 807-3969 | Fax (919) 807-3243
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER