MISSISSIPPI DEPARTMENT OF EDUCATION OFFICE OF SPECIAL EDUCATION EDUCABLE CHILD PROGRAM
P.O. BOX 771, SUITE 301 JACKSON, MISSISSIPPI 39205

INSTRUCTIONS FOR COMPLETING THE SCHOOL DISTRICT APPLICATION FORM: (DI-SE-F10)

General Directions:
•	Please print or type.
•	Complete all blanks or provide an explanation as to why it was left blank.

Section 1:  INFORMATION PERTAINING TO STUDENT:
•	Please use child's legal name – DO NOT USE NICKNAME.
•	Complete Date of Birth, Age, Sex and Race.
•	Complete Public School District of student’s residence.
•	Complete the name of the Private School.
•	Complete MSIS ID number.
•	Provide the current date of the eligibility located on the Determination of Eligibility.
•	Complete the date of the Annual IEP and the Revised IEP (If applicable).
•	Circle Type of Disability: This should be the same information as contained on the Determination of Eligibility.

Section 2:  INFORMATION PERTAINING TO PUBLIC SCHOOL DISTRICT TO WHERE WARRANT SHOULD BE MAILED:
•	Complete name of school district.
•	Complete address, city, state and zip of the school district.
•	Name, email address and phone number of contact person. Contact person is the person who is responsible for the Educable Child Program for the district.

Section 3:  CERTIFICATION OF PUBLIC SCHOOL DISTRICT:
•	Complete student's name (Same information as found in Section 1: Information Pertaining to Student).
•	Complete blank lines.
•	Have the District Superintendent sign and date the document.

Section 4:  INFORMATION PERTAINING TO PRIVATE SCHOOL/FACILITY.
•	Complete the Name of the School/Facility.
•	Complete address, city, state and zip of the school district.
•	Complete Date services began to Date School session ends and Total number of session days.
•	Check type of placement for student.
•	Have the Private School Official sign and date the document.

NOTE: An incomplete application or missing documents will result in the application being returned and will delay approval. Make sure all documents submitted are legible. Faxed copies are not acceptable.

July 2022
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’s residence: District Name: 	

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 ID #:  	

DATE OF CURRENT ELIGIBILITY: _ 	

DATE OF CURRENT IEP:  	

TYPE OF DISABILITY (Circle the Child’s Primary Disability)

1.	Intellectual Disability
2.	Specific Learning Disability
3.	Language/Speech Impaired
4.	Hearing Impaired
5.	Visually Impaired
6.	Deaf-Blind
7.	Emotional Disability

8.	Other Health Impairment
9.	Multiple Disabilities
10.	Autism
11.	Developmentally Delayed
12.	Traumatic Brain Injury
13.	Orthopedic Impairment

2.	INFORMATION PERTAINING TO PUBLIC SCHOOL DISTRICT TO WHERE WARRANT SHOULD BE MAILED

Name of School District: 	

Address:					 (Street, Route and/or Box No.)	(City)	(State)	(Zip)

Name of district contact person: 	

Email address of district contact person:  	

Phone Number:  	

3.	CERTIFICATION OF PUBLIC SCHOOL DISTRICT:  	

Name of Student: 	

a.	SPECIFIC reasons (such as additional support aids and services) that the above-named student cannot be provided a FAPE in an existing or a modified program are:

b.	State-funded institutions have been contacted to determine if placement would be appropriate:
b.	
Yes 	

No  	

c.	The District is aware that if it does make an out-of-district placement consistent with State regulations, the district must pay an amount to be established annually in the OSE Ed Child Procedures for any Educable Child Application made by the district. The remainder of the total cost will be paid from State and Federal funds, as available and/or needed. If State monies are not sufficient to fund all applications, there will be a ratable reduction for all recipients.

d.	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.

e.	Application for financial assistance, as provided by MS Code 37-23-69, 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. 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.

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.
 	Intermediate Care Facility for the Intellectual Disability (ICF-ID) Day
 	Intermediate Care Facility for the Intellectual Disability (ICF-ID)
 	Psychiatric Day Treatment
 	Psychiatric Residential Treatment Facility (PRTF)
 	Private Special School

 	
(Date)	(District Superintendent’s Signature)

4.	INFORMATION PERTAINING TO PRIVATE SCHOOL/FACILITY (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:

 	to	School Program:  	
(Date services began)	(Date school session ends)	(Total number of session days)

 	
(Date)	(Signature and Title of Private School Official)