OMB NO. 1820-0550

**Expires: 12/31/2009**

**ANNUAL STATE APPLICATION UNDER PART C OF THE\
INDIVIDUALS WITH DISABILITIES EDUCATION ACT AS AMENDED IN 2004\
FEDERAL FISCAL YEAR 2009**

**CFDA No. 84.181A**

**ED FORM No. 1 B20\--26P**

**UNITED STATES DEPARTMENT OF EDUCATION**

**OFFICE OF SPECIAL EDUCATION PROGRAMS**

**Washington, DC 20202-2600**

**Section I**

# A. Submission Statements for Part C of IDEA

Select 1 or 2 below. Check 3 if appropriate.

1\. \_\_\_\_\_ The State\'s policies, procedures, methods, descriptions,
and assurances meet all application requirements of Part C of the Act as
found in PL 108-446, the Individuals with Disabilities Education
Improvement Act of 2004 and applicable regulations (IDEA). The State is
able to provide and/or meet all policies, procedures, methods,
descriptions, and assurances, found in Sections II.A and II.B of this
Application.

> By selecting this submission statement the State has submitted the new
> and/or revisions to State policies, procedures, methods, and
> descriptions that meet all requirements found in Section II.A.

2\. \_\_\_\_\_ The State cannot provide policies, procedures, methods,
descriptions, and/or assurances for all application requirements of Part
C of the Act as found in PL 108-446, the Individuals with Disabilities
Education Improvement Act of 2004. The State has determined that [it is
unable]{.underline} to provide the policies, procedures, methods,
descriptions, and/or assurances [that are checked \'No\' in Sections
II.A and II.B]{.underline}. However, the State assures that throughout
the period of this grant award the State will operate consistent with
all requirements of IDEA in PL 108-446 and applicable regulations. The
State will develop and/or make such changes to existing policies,
procedures, methods, descriptions, and assurances as are necessary to
bring the policies, procedures, methods, descriptions, and assurances
into compliance with the requirements of the IDEA, as amended, as soon
as possible, and not later than June 30, 2010. [The State has included
the date by which it expects to complete necessary changes associated
with policies, procedures, methods, descriptions, and assurances marked
\'No\'. The items checked 'Yes' are enclosed with this
application]{.underline}.[^1]

Optional:

3\. \_\_\_\_\_ The State is submitting new or modified State policies
and procedures previously submitted to the Department and has checked,
under Section II.A, the appropriate \'R\' cell(s) found in the \'Yes\'
column. These modifications are: (1) deemed necessary by the State, for
example when the State revises applicable State law or regulations; (2)
required by the Secretary because there is a new interpretation of the
Act or regulations by a Federal court or the State\'s highest court;
and/or (3) because of an official finding of noncompliance with Federal
law or regulation.

## B. Conditional Approval for Current Grant Year

If the State received conditional approval for the current grant year,
check the appropriate statement(s) below:

1\. Conditional Approval Related to Assurances in Section II.A:

> \_\_\_\_\_ a. Sections II.A and II.B provide documentation of
> completion of all issues identified in the FFY 2008 conditional
> approval letter.
>
> \_\_\_\_\_ b. As noted in Sections II.A and II.B, the State has not
> completed all issues identified in the FFY 2008 conditional approval
> letter.

2\. **Conditional Approval Related to Other Issues:**

> \_\_\_\_\_ a. The State previously submitted documentation of
> completion of all issues identified in the FFY 2008 conditional
> approval letter.
>
> \_\_\_\_\_ b. The State is attaching documentation of completion of
> all issues identified in the FFY 2008 conditional approval letter.
> *(Attach documentation showing completion of all issues.)*
>
> \_\_\_\_\_ c. The State has not completed all issues identified in the
> FFY 2008 conditional approval letter. *(Attach documentation showing
> completion of any issues and a list of items not yet completed.)*

### Section II

# A. State Policies, Procedures, Methods, and Descriptions

As checked below, the State hereby declares that it has or has not filed
the following policies, procedures, methods, and descriptions with the
U.S. Department of Education, and, as of the date of the signature
below, affirms and incorporates by reference those policies, procedures,
methods, and descriptions with respect to Part C of PL 108-446.

+---+---+---+----------+------------------------------------------------+
| * |   |   |          | ##### N = \'New\' Policy and/or Procedure      |
| C |   |   |          |                                                |
| h |   |   |          | *R = \'Revised\' Policy and/or Procedure*      |
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| c |   |   |          | *OF = Policy and/or Procedure is already \'On  |
| k |   |   |          | File\' with the USDE*                          |
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+---+---+---+----------+------------------------------------------------+
| * | * | * |          | **State Policies, Procedures, Methods, and     |
| * | * | * |          | Descriptions**                                 |
| N | R | O |          |                                                |
| * | * | F |          |                                                |
| * | * | * |          |                                                |
|   |   | * |          |                                                |
+---+---+---+----------+------------------------------------------------+
|   |   |   |          | **State Policies and Procedures**              |
+---+---+---+----------+------------------------------------------------+
|   |   |   |          | 1\. As required in 20 U.S.C. 1432(5)(A) and    |
|   |   |   |          | 1435(a)(1), the State has provided its         |
|   |   |   |          | policies and/or procedures regarding the       |
|   |   |   |          | State\'s definition of \'developmental delay\' |
|   |   |   |          | to ensure that a rigorous definition of the    |
|   |   |   |          | term \'developmental delay\' will be used by   |
|   |   |   |          | the State in carrying out programs under this  |
|   |   |   |          | Part in order to appropriately identify        |
|   |   |   |          | infants and toddlers with disabilities that    |
|   |   |   |          | are in need of services under this Part.       |
+---+---+---+----------+------------------------------------------------+
|   |   |   |          | 2\. As required in 20 U.S.C. 1437(a)(9)(B),    |
|   |   |   |          | the State has provided its policies and/or     |
|   |   |   |          | procedures to ensure review of the child\'s    |
|   |   |   |          | program options for the period from the        |
|   |   |   |          | child\'s third birthday through the remainder  |
|   |   |   |          | of the school year.                            |
+---+---+---+----------+------------------------------------------------+
|   |   |   |          | 3\. As required in 20 U.S.C. 1437(a)(9)(C),    |
|   |   |   |          | the State has provided its policies and/or     |
|   |   |   |          | procedures to ensure the establishment of a    |
|   |   |   |          | transition plan, including, as appropriate,    |
|   |   |   |          | steps to exit from the program.                |
+---+---+---+----------+------------------------------------------------+
|   |   |   |          | 4\. As required in 20 U.S.C. 1437(a)(6), the   |
|   |   |   |          | State has provided its policies and procedures |
|   |   |   |          | that require the referral for early            |
|   |   |   |          | intervention services under this part of a     |
|   |   |   |          | child under the age of 3 who - (A) is involved |
|   |   |   |          | in a substantiated case of abuse or neglect;   |
|   |   |   |          | or (B) is identified as affected by illegal    |
|   |   |   |          | substance abuse, or withdrawal symptoms        |
|   |   |   |          | resulting from prenatal drug exposure.         |
+---+---+---+----------+------------------------------------------------+
|   |   |   |          | 5\. As required in 20 U.S.C. 1437(a)(9)(A),    |
|   |   |   |          | the State has provided its policies and        |
|   |   |   |          | procedures that ensures a smooth transition    |
|   |   |   |          | for toddlers receiving early intervention      |
|   |   |   |          | services under this part (and children         |
|   |   |   |          | receiving those services under by 20 U.S.C     |
|   |   |   |          | 1435(c)) to preschool, school, other           |
|   |   |   |          | appropriate services, or exiting the program,  |
|   |   |   |          | including a description of how: (i) the        |
|   |   |   |          | families of such toddlers and children will be |
|   |   |   |          | included in the transition plans required 20   |
|   |   |   |          | U.S.C. 1437(a)(9)(C); and (ii) the lead agency |
|   |   |   |          | designated or established under 20 U.S.C.      |
|   |   |   |          | 1435(a)(10) will (I) notify the local          |
|   |   |   |          | educational agency for the area in which such  |
|   |   |   |          | a child resides that the child will shortly    |
|   |   |   |          | reach the age of eligibility for preschool     |
|   |   |   |          | services under Part B, as determined in        |
|   |   |   |          | accordance with State law; (II) in the case of |
|   |   |   |          | a child who may be eligible for such preschool |
|   |   |   |          | services, with the approval of the family of   |
|   |   |   |          | the child, convene a conference among the lead |
|   |   |   |          | agency, the family, and the local educational  |
|   |   |   |          | agency not less than 90 days (and at the       |
|   |   |   |          | discretion of all such parties, not more than  |
|   |   |   |          | 9 months) before the child is eligible for the |
|   |   |   |          | preschool services, to discuss any such        |
|   |   |   |          | services that the child may receive; and (III) |
|   |   |   |          | in the case of a child who may not be eligible |
|   |   |   |          | for such preschool services, with the approval |
|   |   |   |          | of the family, make reasonable efforts to      |
|   |   |   |          | convene a conference among the lead agency,    |
|   |   |   |          | the family, and providers of other appropriate |
|   |   |   |          | services for children who are not eligible for |
|   |   |   |          | preschool services under Part B, to discuss    |
|   |   |   |          | the appropriate services that the child may    |
|   |   |   |          | receive.                                       |
+---+---+---+----------+------------------------------------------------+
|   |   |   |          | ###### Optional Policies/Methods               |
|   |   |   |          |                                                |
|   |   |   |          | Type in 'NA' for not applicable under 'No' in  |
|   |   |   |          | the cells to the left if the State has not     |
|   |   |   |          | exercised this option.                         |
+---+---+---+----------+------------------------------------------------+
|   |   |   |          | 6.  As required in 20 U.S.C. 1437(a)(4), if    |
|   |   |   |          |     the State provides services to at-risk     |
|   |   |   |          |     infants and toddlers through the statewide |
|   |   |   |          |     system, the State has provided its: 1)     |
|   |   |   |          |     description of services to at-risk infants |
|   |   |   |          |     and toddlers, and 2) definition of         |
|   |   |   |          |     \'at-risk\' under 20 U.S.C. 1432(5)(B)(i). |
+---+---+---+----------+------------------------------------------------+
|   |   |   |          | *Enter \'NA\' in the cells to the left if the  |
|   |   |   |          | State does not have a system of payment. (See  |
|   |   |   |          | Section IV.A)*                                 |
|   |   |   |          |                                                |
|   |   |   |          | 7\. As required in 20 U.S.C. 1432(4)(B) and    |
|   |   |   |          | 1437(a)(3)(A), the State has provided its      |
|   |   |   |          | policies and/or procedures that identify the   |
|   |   |   |          | State\'s system of payments for Part C         |
|   |   |   |          | services.                                      |
+---+---+---+----------+------------------------------------------------+
|   |   |   |          | Enter \'NA\' in the cells to the left if this  |
|   |   |   |          | statement is not applicable; otherwise check   |
|   |   |   |          | the \'N\' cell under the \'Yes\' column and    |
|   |   |   |          | attach all policies.                           |
|   |   |   |          |                                                |
|   |   |   |          | 8\. As described in 20 U.S.C. 1435(c) the      |
|   |   |   |          | State has provided its policy, developed and   |
|   |   |   |          | implemented jointly by the lead agency and the |
|   |   |   |          | State educational agency, under which parents  |
|   |   |   |          | of children with disabilities who are eligible |
|   |   |   |          | for services under 20 U.S.C. 1419 and          |
|   |   |   |          | previously received services under this part,  |
|   |   |   |          | may choose the continuation of early           |
|   |   |   |          | intervention services (which includes an       |
|   |   |   |          | educational component that promotes school     |
|   |   |   |          | readiness and incorporates preliteracy,        |
|   |   |   |          | language, and numeracy skills) for such        |
|   |   |   |          | children under this part until such children   |
|   |   |   |          | enter, or are eligible under State law to      |
|   |   |   |          | enter, kindergarten.                           |
|   |   |   |          |                                                |
|   |   |   |          | > The statewide system ensures that\--         |
|   |   |   |          | >                                              |
|   |   |   |          | > \(A\) parents of children with disabilities  |
|   |   |   |          | > served pursuant to 20 U.S.C. 1435(c) are     |
|   |   |   |          | > provided annual notice that contains\--      |
|   |   |   |          | >                                              |
|   |   |   |          | > \(i\) a description of the rights of such    |
|   |   |   |          | > parents to elect to receive services         |
|   |   |   |          | > pursuant to 20 U.S.C. 1435(c) or under Part  |
|   |   |   |          | > B; and                                       |
|   |   |   |          | >                                              |
|   |   |   |          | > \(ii\) an explanation of the differences     |
|   |   |   |          | > between services provided pursuant to 20     |
|   |   |   |          | > U.S.C. 1435(c) and services provided under   |
|   |   |   |          | > Part B, including\--                         |
|   |   |   |          | >                                              |
|   |   |   |          | > \(I\) types of services and the locations at |
|   |   |   |          | > which the services are provided;             |
|   |   |   |          | >                                              |
|   |   |   |          | > \(II\) applicable procedural safeguards; and |
|   |   |   |          | >                                              |
|   |   |   |          | > \(III\) possible costs (including any fees   |
|   |   |   |          | > to be charged to families as described in 20 |
|   |   |   |          | > U.S.C. 1432(4)(B)), if any, to parents of    |
|   |   |   |          | > infants or toddlers with disabilities;       |
|   |   |   |          | >                                              |
|   |   |   |          | > \(B\) services provided pursuant to 20       |
|   |   |   |          | > U.S.C. 1435(c) include an educational        |
|   |   |   |          | > component that promotes school readiness and |
|   |   |   |          | > incorporates preliteracy, language, and      |
|   |   |   |          | > numeracy skills;                             |
|   |   |   |          | >                                              |
|   |   |   |          | > \(C\) the State policy will not affect the   |
|   |   |   |          | > right of any child served pursuant to 20     |
|   |   |   |          | > U.S.C. 1435(c) to instead receive a free     |
|   |   |   |          | > appropriate public education under Part B;   |
|   |   |   |          | >                                              |
|   |   |   |          | > \(D\) all early intervention services        |
|   |   |   |          | > outlined in the child\'s individualized      |
|   |   |   |          | > family service plan under 20 U.S.C. 1436 are |
|   |   |   |          | > continued while any eligibility              |
|   |   |   |          | > determination is being made for services     |
|   |   |   |          | > under 20 U.S.C. 1435(c);                     |
|   |   |   |          | >                                              |
|   |   |   |          | > \(E\) the parents of infants or toddlers     |
|   |   |   |          | > with disabilities (as defined in 20 U.S.C.   |
|   |   |   |          | > 1432(5)(A)) provide informed written consent |
|   |   |   |          | > to the State, before such infants or         |
|   |   |   |          | > toddlers reach 3 years of age, as to whether |
|   |   |   |          | > such parents intend to choose the            |
|   |   |   |          | > continuation of early intervention services  |
|   |   |   |          | > pursuant to 20 U.S.C. 1435(c) for such       |
|   |   |   |          | > infants or toddlers;                         |
|   |   |   |          | >                                              |
|   |   |   |          | > \(F\) the requirements under 20 U.S.C.       |
|   |   |   |          | > 1437(a)(9) shall not apply with respect to a |
|   |   |   |          | > child who is receiving services in           |
|   |   |   |          | > accordance with 20 U.S.C. 1435(c) until not  |
|   |   |   |          | > less than 90 days (and at the discretion of  |
|   |   |   |          | > the parties to the conference, not more than |
|   |   |   |          | > 9 months) before the time the child will no  |
|   |   |   |          | > longer receive those services; and           |
|   |   |   |          | >                                              |
|   |   |   |          | > \(G\) there will be a referral for           |
|   |   |   |          | > evaluation for early intervention services   |
|   |   |   |          | > of a child who experiences a substantiated   |
|   |   |   |          | > case of trauma due to exposure to family     |
|   |   |   |          | > violence (as defined in section 320 of the   |
|   |   |   |          | > Family Violence Prevention and Services      |
|   |   |   |          | > Act).                                        |
|   |   |   |          | >                                              |
|   |   |   |          | > The State shall submit to the Secretary, in  |
|   |   |   |          | > the State\'s report under 20 U.S.C.          |
|   |   |   |          | > 1437(b)(4)(A), a report on the number and    |
|   |   |   |          | > percentage of children with disabilities who |
|   |   |   |          | > are eligible for services under 20 U.S.C.    |
|   |   |   |          | > 1419 but whose parents choose for such       |
|   |   |   |          | > children to continue to receive early        |
|   |   |   |          | > intervention services under this part.       |
|   |   |   |          | >                                              |
|   |   |   |          | > The policy shall include a description of    |
|   |   |   |          | > the funds (including an identification as    |
|   |   |   |          | > Federal, State, or local funds) that will be |
|   |   |   |          | > used to ensure that the option described 20  |
|   |   |   |          | > U.S.C. 1435(c)(1) is available to eligible   |
|   |   |   |          | > children and families who provide the        |
|   |   |   |          | > consent described in 20 U.S.C.               |
|   |   |   |          | > 1435(c)(2)(E), including fees (if any) to be |
|   |   |   |          | > charged to families as described in 20       |
|   |   |   |          | > U.S.C. 1432(4)(B).                           |
|   |   |   |          | >                                              |
|   |   |   |          | > In accordance with 20 U.S.C. 1435(c)(5)(A),  |
|   |   |   |          | > when providing services to a child with a    |
|   |   |   |          | > disability who is eligible for services      |
|   |   |   |          | > under 20 U.S.C. 1419 the State is not        |
|   |   |   |          | > required to provide the child with a free    |
|   |   |   |          | > appropriate public education under Part B    |
|   |   |   |          | > for the period of time in which the child is |
|   |   |   |          | > receiving services under Part C.             |
+---+---+---+----------+------------------------------------------------+
|   |   |   |          | Enter \'NA\' in the cells to the left if this  |
|   |   |   |          | statement is not applicable; otherwise check   |
|   |   |   |          | either the \'N\' or \'R\' cell under the       |
|   |   |   |          | \'Yes\' column and attach appropriate written  |
|   |   |   |          | methods. See the Optional Technical Assistance |
|   |   |   |          | Checklist for the full provisions of 20 U.S.C. |
|   |   |   |          | 1440.                                          |
|   |   |   |          |                                                |
|   |   |   |          | 9\. The State has chosen to meet the           |
|   |   |   |          | requirement to establish financial             |
|   |   |   |          | responsibility for early intervention services |
|   |   |   |          | under 20 U.S.C. 1440(b)(1) through             |
|   |   |   |          | \'appropriate written methods\' under 20       |
|   |   |   |          | U.S.C. 1440(b)(3)(C) other than State statute  |
|   |   |   |          | or regulation or signed interagency            |
|   |   |   |          | agreements.                                    |
+---+---+---+----------+------------------------------------------------+
|   |   |   |          | ####### Descriptions                           |
+---+---+---+----------+------------------------------------------------+
|   |   |   |          | 10\. As required by Section 427 of the General |
|   |   |   |          | Education Provisions Act (GEPA), the State has |
|   |   |   |          | identified barriers and developed strategies   |
|   |   |   |          | to address the barriers and has provided a     |
|   |   |   |          | description of the steps the State is taking   |
|   |   |   |          | to ensure equitable access to, and             |
|   |   |   |          | participation in Part C.                       |
+---+---+---+----------+------------------------------------------------+
|   |   |   |          | 11\. As required in 20 U.S.C. 1437(a)(3)(B),   |
|   |   |   |          | the State has provided a description of early  |
|   |   |   |          | intervention services to be provided to        |
|   |   |   |          | infants and toddlers with disabilities and     |
|   |   |   |          | their families through the statewide system.   |
+---+---+---+----------+------------------------------------------------+
|   |   |   |          | 12\. As required in 20 U.S.C. 1437(a)(5), the  |
|   |   |   |          | State has provided a description of the uses   |
|   |   |   |          | for which funds will be expended in accordance |
|   |   |   |          | with this part. (*See Section III. If the      |
|   |   |   |          | State is submitting a completed Section III,   |
|   |   |   |          | check 'N' under the 'Yes' column to the        |
|   |   |   |          | left.)*                                        |
+---+---+---+----------+------------------------------------------------+
|   |   |   |          | 13\. As required in 20 U.S.C. 1437(a)(7) the   |
|   |   |   |          | State has provided a description of the        |
|   |   |   |          | procedures used to ensure that resources are   |
|   |   |   |          | made available under this part for all         |
|   |   |   |          | geographic areas within the State.             |
+---+---+---+----------+------------------------------------------------+
|   |   |   |          | 14\. As required in 20 U.S.C. 1437(a)(8) the   |
|   |   |   |          | State has provided a description of the        |
|   |   |   |          | policies and procedures used to ensure that,   |
|   |   |   |          | prior to the adoption by the State of any      |
|   |   |   |          | other policy or procedure necessary to meet    |
|   |   |   |          | the requirements of this part, there are       |
|   |   |   |          | public hearings, adequate notice of the        |
|   |   |   |          | hearings, and an opportunity for comment       |
|   |   |   |          | available to the general public, including     |
|   |   |   |          | individuals with disabilities and parents of   |
|   |   |   |          | infants and toddlers with disabilities.        |
+---+---+---+----------+------------------------------------------------+
|   |   |   |          | 15\. As required in 20 U.S.C. 1437(a)(10) the  |
|   |   |   |          | State has provided a description of State      |
|   |   |   |          | efforts to promote collaboration among Early   |
|   |   |   |          | Head Start programs under section 645A of the  |
|   |   |   |          | Head Start Act, early education and child care |
|   |   |   |          | programs, and services under Part C.           |
+---+---+---+----------+------------------------------------------------+

### B. Assurances and Optional Assurance

The State makes the following assurances and provisions as required by
Part C of the Individuals with Disabilities Education Act. (20 U.S.C.
1431 et.seq.)

+--------+--------+----------------------------------------------------+
| *Check |        | ####### Assurances                                 |
| and    |        |                                                    |
| enter  |        | (20 U.S.C. 1434;1435; and 1437(b))                 |
| d      |        |                                                    |
| ate(s) |        |                                                    |
| as     |        |                                                    |
| appli  |        |                                                    |
| cable* |        |                                                    |
+========+========+====================================================+
| ###### | #####  |                                                    |
| ## Yes | ### No |                                                    |
|        |        |                                                    |
| *(Ass  | *(Ass  |                                                    |
| urance | urance |                                                    |
| is     | cannot |                                                    |
| hereby | be     |                                                    |
| provi  | en     |                                                    |
| ded.)* | sured. |                                                    |
|        | P      |                                                    |
|        | rovide |                                                    |
|        | date   |                                                    |
|        | on     |                                                    |
|        | which  |                                                    |
|        | State  |                                                    |
|        | will   |                                                    |
|        | co     |                                                    |
|        | mplete |                                                    |
|        | c      |                                                    |
|        | hanges |                                                    |
|        | in     |                                                    |
|        | order  |                                                    |
|        | to     |                                                    |
|        | p      |                                                    |
|        | rovide |                                                    |
|        | assura |                                                    |
|        | nce.)* |                                                    |
+--------+--------+----------------------------------------------------+
|        |        | 1\. As applicable, the assurance found in OMB      |
|        |        | Standard Form 424(B) (Assurances for               |
|        |        | Non-Construction Programs), relating to legal      |
|        |        | authority to apply for assistance; access to       |
|        |        | records; conflict of interest; merit systems;      |
|        |        | nondiscrimination; Hatch Act provisions; labor     |
|        |        | standards; flood insurance; environmental          |
|        |        | standards; wild and scenic river systems; historic |
|        |        | preservation; protection of human subjects; animal |
|        |        | welfare; lead-based paint; Single Audit Act; and   |
|        |        | general agreement to comply with all Federal laws, |
|        |        | executive orders and regulations is in place.      |
+--------+--------+----------------------------------------------------+
|        |        | 2\. The State has adopted a policy that            |
|        |        | appropriate early intervention services are        |
|        |        | available to all infants and toddlers with         |
|        |        | disabilities in the State and their families,      |
|        |        | including Indian infants and toddlers with         |
|        |        | disabilities and their families residing on a      |
|        |        | reservation geographically located in the State,   |
|        |        | infants and toddlers with disabilities who are     |
|        |        | homeless children and their families, and infants  |
|        |        | and toddlers with disabilities who are wards of    |
|        |        | the State; and has in effect a statewide           |
|        |        | comprehensive, coordinated, multidisciplinary,     |
|        |        | interagency system to provide early intervention   |
|        |        | services, for infants and toddlers with            |
|        |        | disabilities and their families, that meet the     |
|        |        | requirements of 20 U.S.C 1401, and 1431-1443. *See |
|        |        | the Optional Technical Assistance Checklist for    |
|        |        | the full provisions of 1401 and 1432.*             |
+--------+--------+----------------------------------------------------+
|        |        | 3\. The State has in effect a policy that ensures  |
|        |        | that appropriate early intervention services based |
|        |        | on scientifically based research, to the extent    |
|        |        | practicable, are available to all infants and      |
|        |        | toddlers with disabilities and their families,     |
|        |        | including Indian infants and toddlers with         |
|        |        | disabilities and their families residing on a      |
|        |        | reservation geographically located in the State    |
|        |        | and infants and toddlers with disabilities who are |
|        |        | homeless children and their families in accordance |
|        |        | with 20 U.S.C. 1435(a)(2).                         |
+--------+--------+----------------------------------------------------+
|        |        | 4\. The State has in effect a timely,              |
|        |        | comprehensive, multidisciplinary evaluation of the |
|        |        | functioning of each infant or toddler with a       |
|        |        | disability in the State, and a family-directed     |
|        |        | identification of the needs of each family of such |
|        |        | an infant or toddler, to assist appropriately in   |
|        |        | the development of the infant or toddler in        |
|        |        | accordance with 20 U.S.C. 1435(a)(3).              |
+--------+--------+----------------------------------------------------+
|        |        | 5\. For each infant or toddler with a disability   |
|        |        | in the State, the State has an individualized      |
|        |        | family service plan in accordance with 20 U.S.C.   |
|        |        | 1436, including service coordination services in   |
|        |        | accordance with such service plan. (20 U.S.C.      |
|        |        | 1435(a)(4)) *See Optional Technical Assistance     |
|        |        | Checklist for the full provisions of 20 U.S.C.     |
|        |        | 1436.*                                             |
+--------+--------+----------------------------------------------------+
|        |        | 6\. The State has a comprehensive child find       |
|        |        | system, consistent with Part B, including a system |
|        |        | for making referrals to service providers that     |
|        |        | includes timelines and provides for participation  |
|        |        | by primary referral sources and that ensures       |
|        |        | rigorous standards for appropriately identifying   |
|        |        | infants and toddlers with disabilities for         |
|        |        | services under this part that will reduce the need |
|        |        | for future services. (20 U.S.C. 1435(a)(5))        |
+--------+--------+----------------------------------------------------+
|        |        | 7\. The State has a public awareness program       |
|        |        | focusing on early identification of infants and    |
|        |        | toddlers with disabilities, including the          |
|        |        | preparation and dissemination by the lead agency   |
|        |        | designated or established under 20 U.S.C.          |
|        |        | 1435(a)(10) to all primary referral sources,       |
|        |        | especially hospitals and physicians, of            |
|        |        | information to be given to parents, especially to  |
|        |        | inform parents with premature infants, or infants  |
|        |        | with other physical risk factors associated with   |
|        |        | learning or developmental complications, on the    |
|        |        | availability of early intervention services under  |
|        |        | this part and of services under 20 U.S.C. 1419,    |
|        |        | and procedures for assisting such sources in       |
|        |        | disseminating such information to parents of       |
|        |        | infants and toddlers with disabilities. (20 U.S.C. |
|        |        | 1435(a)(6))                                        |
+--------+--------+----------------------------------------------------+
|        |        | 8\. The State has a central directory that         |
|        |        | includes information on early intervention         |
|        |        | services, resources, and experts available in the  |
|        |        | State and research and demonstration projects      |
|        |        | being conducted in the State. (20 U.S.C.           |
|        |        | 1435(a)(7))                                        |
+--------+--------+----------------------------------------------------+
|        |        | 9\. The State has a comprehensive system of        |
|        |        | personnel development, including the training of   |
|        |        | paraprofessionals and the training of primary      |
|        |        | referral sources with respect to the basic         |
|        |        | components of early intervention services          |
|        |        | available in the State that                        |
|        |        |                                                    |
|        |        | > \(A\) includes\--                                |
|        |        | >                                                  |
|        |        | > \(i\) implementing innovative strategies and     |
|        |        | > activities for the recruitment and retention of  |
|        |        | > early education service providers;               |
|        |        | >                                                  |
|        |        | > \(ii\) promoting the preparation of early        |
|        |        | > intervention providers who are fully and         |
|        |        | > appropriately qualified to provide early         |
|        |        | > intervention services under this part; and       |
|        |        | >                                                  |
|        |        | > \(iii\) training personnel to coordinate         |
|        |        | > transition services for infants and toddlers     |
|        |        | > served under this part from a program providing  |
|        |        | > early intervention services under this part and  |
|        |        | > under Part B (other than 20 U.S.C. 1419), to a   |
|        |        | > preschool program receiving funds under 20       |
|        |        | > U.S.C. 1419, or another appropriate program; and |
|        |        | >                                                  |
|        |        | > \(B\) may include\--                             |
|        |        | >                                                  |
|        |        | > \(i\) training personnel to work in rural and    |
|        |        | > inner-city areas; and                            |
|        |        | >                                                  |
|        |        | > \(ii\) training personnel in the emotional and   |
|        |        | > social development of young children.            |
|        |        | >                                                  |
|        |        | > (20 U.S.C. 1435(a)(8)(A) and (B))                |
+--------+--------+----------------------------------------------------+
|        |        | 10\. The State has policies and procedures         |
|        |        | relating to the establishment and maintenance of   |
|        |        | qualifications to ensure that personnel necessary  |
|        |        | to carry out this part are appropriately and       |
|        |        | adequately prepared and trained, including the     |
|        |        | establishment and maintenance of qualifications    |
|        |        | that are consistent with any State-approved or     |
|        |        | recognized certification, licensing, registration, |
|        |        | or other comparable requirements that apply to the |
|        |        | area in which such personnel are providing early   |
|        |        | intervention services, except that nothing in this |
|        |        | part (including this paragraph) shall be construed |
|        |        | to prohibit the use of paraprofessionals and       |
|        |        | assistants who are appropriately trained and       |
|        |        | supervised in accordance with State law,           |
|        |        | regulation, or written policy, to assist in the    |
|        |        | provision of early intervention services under     |
|        |        | this part to infants and toddlers with             |
|        |        | disabilities. (20 U.S.C. 1432 and 1435(a)(9))      |
+--------+--------+----------------------------------------------------+
|        |        | 11\. The State has a single line of responsibility |
|        |        | in a lead agency designated or established by the  |
|        |        | Governor for carrying out -                        |
|        |        |                                                    |
|        |        | > \(A\) the general administration and supervision |
|        |        | > of programs and activities receiving assistance  |
|        |        | > under 20 U.S.C. 1433, and the monitoring of      |
|        |        | > programs and activities used by the State to     |
|        |        | > carry out this part, whether or not such         |
|        |        | > programs or activities are receiving assistance  |
|        |        | > made available under 20 U.S.C. 1433, to ensure   |
|        |        | > that the State complies with this part;          |
|        |        | >                                                  |
|        |        | > \(B\) the identification and coordination of all |
|        |        | > available resources within the State from        |
|        |        | > Federal, State, local, and private sources;      |
|        |        | >                                                  |
|        |        | > \(C\) the assignment of financial responsibility |
|        |        | > in accordance with 20 U.S.C. 1437(a)(2) to the   |
|        |        | > appropriate agencies;                            |
|        |        | >                                                  |
|        |        | > \(D\) the development of procedures to ensure    |
|        |        | > that services are provided to infants and        |
|        |        | > toddlers with disabilities and their families    |
|        |        | > under this part in a timely manner pending the   |
|        |        | > resolution of any disputes among public agencies |
|        |        | > or service providers;                            |
|        |        | >                                                  |
|        |        | > \(E\) the resolution of intra- and interagency   |
|        |        | > disputes; and                                    |
|        |        | >                                                  |
|        |        | > \(F\) the entry into formal interagency          |
|        |        | > agreements that define the financial             |
|        |        | > responsibility of each agency for paying for     |
|        |        | > early intervention services (consistent with     |
|        |        | > State law) and procedures for resolving disputes |
|        |        | > and that include all additional components       |
|        |        | > necessary to ensure meaningful cooperation and   |
|        |        | > coordination. *See Optional Technical Assistance |
|        |        | > Checklist for the full provisions of 20 U.S.C.   |
|        |        | > 1440.*                                           |
|        |        | >                                                  |
|        |        | > (20 U.S.C. 1435(a)(10)(A)-(F) and 1440)          |
+--------+--------+----------------------------------------------------+
|        |        | 12\. The State has a policy pertaining to the      |
|        |        | contracting or making of other arrangements with   |
|        |        | service providers to provide early intervention    |
|        |        | services in the State, consistent with the         |
|        |        | provisions of Part C, including the contents of    |
|        |        | the application used and the conditions of the     |
|        |        | contract or other arrangements. (20 U.S.C.         |
|        |        | 1435(a)(11))                                       |
+--------+--------+----------------------------------------------------+
|        |        | 13\. The State has a procedure for securing timely |
|        |        | reimbursements of funds used under this part in    |
|        |        | accordance with 20 U.S.C. 1440(a). *See Optional   |
|        |        | Technical Assistance Checklist for the full        |
|        |        | provisions of 20 U.S.C. 1440.* (20 U.S.C.          |
|        |        | 1435(a)(12) and 1440)                              |
+--------+--------+----------------------------------------------------+
|        |        | 14. The State has procedural safeguards with       |
|        |        |     respect to programs under this part, as        |
|        |        |     required by 20 U.S.C. 1439. (20 U.S.C.         |
|        |        |     1435(a)(13)) *See Optional Technical           |
|        |        |     Assistance Checklist for applicable provisions |
|        |        |     of 20 U.S.C. 1415 and 1439.*                   |
+--------+--------+----------------------------------------------------+
|        |        | 15\. The State has a system for compiling data     |
|        |        | requested by the Secretary under section 618 that  |
|        |        | relates to this part. (20 U.S.C. 1418, 1435(a)(14) |
|        |        | and 1442)                                          |
+--------+--------+----------------------------------------------------+
|        |        | 16\. The State has a State interagency             |
|        |        | coordinating council that meets the requirements   |
|        |        | of 20 U.S.C. 1441. (20 U.S.C. 1435(a)(15)) *See    |
|        |        | Optional Technical Assistance Checklist for the    |
|        |        | full provisions of 20 U.S.C. 1441.*                |
+--------+--------+----------------------------------------------------+
|        |        | 17\. The State has policies and procedures to      |
|        |        | ensure that, consistent with 20 U.S.C 1436(d)(5):  |
|        |        | A) to the maximum extent appropriate, early        |
|        |        | intervention services are provided in natural      |
|        |        | environments; and B) the provision of early        |
|        |        | intervention services for any infant or toddler    |
|        |        | with a disability occurs in a setting other than a |
|        |        | natural environment that is most appropriate, as   |
|        |        | determined by the parent and the individualized    |
|        |        | family service plan team, only when early          |
|        |        | intervention cannot be achieved satisfactorily for |
|        |        | the infant or toddler in a natural environment.    |
|        |        | (20 U.S.C. 1435(a)(16))                            |
+--------+--------+----------------------------------------------------+
|        |        | 18\. The State ensures that Federal funds made     |
|        |        | available under 20 U.S.C. 1443 will be expended in |
|        |        | accordance with this part. (20 U.S.C. 1437(b)(1)   |
|        |        | and 1438)                                          |
+--------+--------+----------------------------------------------------+
|        |        | 19\. The State ensures that it has methods in      |
|        |        | place to comply with the requirements of 20 U.S.C. |
|        |        | 1440. (20 U.S.C. 1437(b)(2)) *State\'s response    |
|        |        | should be consistent with Certification #3 below.* |
+--------+--------+----------------------------------------------------+
|        |        | 20\. The State ensures that the control of funds   |
|        |        | provided under 20 U.S.C. 1443, and title to        |
|        |        | property derived from those funds, will be in a    |
|        |        | public agency for the uses and purposes provided   |
|        |        | in this part and that a public agency will         |
|        |        | administer such funds and property. (20 U.S.C.     |
|        |        | 1437(b)(3))                                        |
+--------+--------+----------------------------------------------------+
|        |        | 21\. The State ensures that provisions shall be    |
|        |        | made for\--                                        |
|        |        |                                                    |
|        |        | > \(A\) making such reports in such form and       |
|        |        | > containing such information as the Secretary may |
|        |        | > require to carry out the Secretary\'s functions  |
|        |        | > under this part; and                             |
|        |        | >                                                  |
|        |        | > \(B\) keeping such reports and affording such    |
|        |        | > access to the reports as the Secretary may find  |
|        |        | > necessary to ensure the correctness and          |
|        |        | > verification of those reports and proper         |
|        |        | > disbursement of Federal funds under this part.   |
|        |        | > (20 U.S.C. 1437(b)(4))                           |
+--------+--------+----------------------------------------------------+
|        |        | 22\. The State ensures that the Federal funds made |
|        |        | available under 20 U.S.C. 1443 to the State\--     |
|        |        |                                                    |
|        |        | > \(A\) will not be commingled with State funds;   |
|        |        | > and                                              |
|        |        | >                                                  |
|        |        | > \(B\) will be used so as to supplement the level |
|        |        | > of State and local funds expended for infants    |
|        |        | > and toddlers with disabilities and their         |
|        |        | > families and in no case to supplant those State  |
|        |        | > and local funds. (20 U.S.C. 1437(b)(5))          |
+--------+--------+----------------------------------------------------+
|        |        | 23\. The State ensures that fiscal control and     |
|        |        | fund accounting procedures will be adopted as may  |
|        |        | be necessary to ensure proper disbursement of, and |
|        |        | accounting for, Federal funds paid under 20 U.S.C. |
|        |        | 1443 to the State. (20 U.S.C. 1437(b)(6))          |
+--------+--------+----------------------------------------------------+
|        |        | 24\. The State ensures that policies and           |
|        |        | procedures have been adopted to ensure meaningful  |
|        |        | involvement of underserved groups, including       |
|        |        | minority, low-income, homeless, and rural families |
|        |        | and children with disabilities who are wards of    |
|        |        | the State, in the planning and implementation of   |
|        |        | all the requirements of Part C. (20 U.S.C.         |
|        |        | 1437(b)(7))                                        |
+--------+--------+----------------------------------------------------+
|        |        | 25\. The State assures that it shall provide other |
|        |        | information and assurances as the Secretary may    |
|        |        | reasonably require by regulation. (20 U.S.C.       |
|        |        | 1437(b)(8).                                        |
+--------+--------+----------------------------------------------------+
|        |        | ####### Optional Assurance                         |
+--------+--------+----------------------------------------------------+
|        |        | > *Enter \'NA' in the cells to the left if this    |
|        |        | > assurance is not applicable.*                    |
|        |        |                                                    |
|        |        | 26\. The State has adopted a policy that includes  |
|        |        | making ongoing good-faith efforts to recruit and   |
|        |        | hire appropriately and adequately trained          |
|        |        | personnel to provide early intervention services   |
|        |        | to infants and toddlers with disabilities,         |
|        |        | including, in a geographic area of the State where |
|        |        | there is a shortage of such personnel, the most    |
|        |        | qualified individuals available who are making     |
|        |        | satisfactory progress toward completing applicable |
|        |        | course work necessary to meet the standards        |
|        |        | described in 20 U.S.C. 1435(a)(9). (20 U.S.C.      |
|        |        | 1435(b))                                           |
+--------+--------+----------------------------------------------------+

### C. Certifications

The State Lead Agency is providing the following certifications:

+--------+-------------------------------------------------------------+
| *      |                                                             |
| *Yes** |                                                             |
+--------+-------------------------------------------------------------+
|        | 1\. The State certifies that ED Form 80-0013,               |
|        | *Certification Regarding Lobbying*, is on file with the     |
|        | Secretary of Education.                                     |
|        |                                                             |
|        | > With respect to the *Certification Regarding Lobbying*    |
|        | > the State recertifies that no Federal appropriated funds  |
|        | > have been paid or will be paid to any person for          |
|        | > influencing or attempting to influence an officer or      |
|        | > employee of any agency, a Member of Congress, an officer  |
|        | > or employee of Congress, or an employee of a Member of    |
|        | > Congress in connection with the making or renewal of      |
|        | > Federal grants under this program; that the State shall   |
|        | > complete and submit Standard Form-LLL, \"Disclosure Form  |
|        | > to Report Lobbying,\" when required (34 CFR Part 82,      |
|        | > Appendix B); and that the State Agency shall require the  |
|        | > full certification, as set forth in 34 CFR Part 82,       |
|        | > Appendix A, in the award documents for all sub awards at  |
|        | > all tiers.                                                |
+--------+-------------------------------------------------------------+
|        | 2\. The State certifies that it has met the certifications  |
|        | in the Education Department General Administrative          |
|        | Regulations (EDGAR) at 34 CFR §80.11 relating to State      |
|        | eligibility, authority and approval to submit and carry out |
|        | the provisions of its State application, and consistency of |
|        | that application with State law are in place within the     |
|        | State.                                                      |
+--------+-------------------------------------------------------------+
|        | 3\. The State certifies that the methods or arrangements to |
|        | establish financial responsibility for early intervention   |
|        | services provided under Part C pursuant to 20 U.S.C.        |
|        | 1440(b) are current as of the date of this Application      |
|        | certification. (20 U.S.C. 1437(a)(2) and 1440). *See Item 9 |
|        | in Section II.A above regarding including, with this        |
|        | Application for the Secretary\'s review, \'other            |
|        | appropriate written methods\' to meet the requirements of   |
|        | 20 U.S.C. 1440(b). State\'s response under Assurance #19    |
|        | above should be consistent with its response to this        |
|        | Certification.*                                             |
+--------+-------------------------------------------------------------+

## D. Statement

I certify that the State of
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ has
provided the policies, procedures, methods, descriptions, and assurances
checked as \'yes\' in Sections II.A and II.B and the certifications
required in Section II.C of this application. These provisions meet the
requirements of Part C of the Individuals with Disabilities Education
Act as found in PL 108-446. The State will operate its Part C program in
accordance with all of the required policies, procedures, methods,
descriptions, assurances and certifications.

If any policies, procedures, methods, descriptions, and assurances have
been checked \'no\', I certify that the State will operate throughout
the period of this grant award consistent with the requirements of the
IDEA as found in PL 108-446 and any applicable regulations, and will
make such changes to existing policies and procedures as are necessary
to bring those policies and procedures into compliance with the
requirements of the IDEA, as amended, as soon as possible, and not later
than June 30, 2010. (34 CFR §76.104)

I, the undersigned authorized official of the

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_,

(Name of State and official name of State lead agency)

am designated under Part C by the Governor of this State to submit this
application for FFY \_\_\_\_\_\_\_ funds under Part C of the Individuals
with Disabilities Education Act (IDEA).

  ----------------------------------- -----------------------------------
  Printed/Typed Name and Title of     
  Authorized Representative of the    
  State:                              

  Signature:                          Date:
  ----------------------------------- -----------------------------------

### Section III

### A. Description of Use of Part C Funds for the Lead Agency

> When completing this section include:

-   Totals for the number of lead agency administrative positions,
    salaries and fringe benefits funded either 100 percent and/or less
    than 100 percent with Part C funds;

-   A general description of the duties which the positions entail; and

-   A subtotal of the amount.

> Identify any administrative positions for which less than 100% of the
> time is spent on Part C and, for each such position, indicate the
> percentage of time spent on Part C and the total amount of salary and
> fringe benefits included in the Part C application budget.

  ------------- ------------- -------- ------------ -------------------------------------
  **Positions   **Number of   **% of   **Salaries & **Description of Duties**
  Funded**      Positions**   Time     Fringe       
                              Spent on Benefits**   
                              Part C**              

  100% funded                                       
  with Part C                                       
  Funds                                             

  \< 100%                                           
  funded with                                       
  Part C Funds                                      

  **Subtotal of                                     
  amount under                                      
  A:**                                              
  ------------- ------------- -------- ------------ -------------------------------------

## Section III (Continued)

## B. Maintenance and Implementation Activities for the Lead Agency

> When completing this section include:

-   A description of the nature and scope of each major activity to be
    carried out under Part C in maintaining and implementing the
    statewide system of early intervention services. Activities could
    include enhancing the Comprehensive System of Personnel Development,
    implementing child find strategies, or ensuring a timely,
    comprehensive, multidisciplinary evaluation for each child;

-   The approximate amount of funds to be spent for each activity; and

-   A subtotal of the amount.

> *(Add columns and rows as needed.)*

+----------------+-----------+-----------------------------------------+
| #######        | **Part C  | **Description of Activities**           |
| Major Activity | Funds to  |                                         |
|                | be        |                                         |
|                | Spent**   |                                         |
+----------------+-----------+-----------------------------------------+
|                |           |                                         |
+----------------+-----------+-----------------------------------------+
|                |           |                                         |
+----------------+-----------+-----------------------------------------+
|                |           |                                         |
+----------------+-----------+-----------------------------------------+
|                |           |                                         |
+----------------+-----------+-----------------------------------------+
| **Subtotal of  |           |                                         |
| amount under   |           |                                         |
| B:**           |           |                                         |
+----------------+-----------+-----------------------------------------+

**Section III (Continued)**

**C. Description of Use of Part C Funds for the Interagency Coordinating
Council (ICC)**

> When completing this section include:

-   Totals for the number of ICC administrative positions, salaries and
    fringe benefits funded either 100 percent and/or less than 100
    percent with Part C funds;

-   A general description of the duties which the positions entail; and

-   A subtotal of the amount.

> Identify any administrative positions for which less than 100% of the
> time is spent on Part C and, for each such position, indicate the
> percentage of time spent on Part C and the total amount of salary and
> fringe benefits included in the Part C application budget.

  ------------- ------------- -------- ------------ -------------------------------------
  **Positions   **Number of   **% of   **Amount of  **Description of Duties**
  Funded**      Positions**   Time     Salaries &   
                              Spent on Fringe       
                              Part C** Benefits**   

  100% funded                                       
  with Part C                                       
  Funds                                             

  \< 100%                                           
  funded with                                       
  Part C Funds                                      

  **Subtotal of                                     
  amount under                                      
  C:**                                              
  ------------- ------------- -------- ------------ -------------------------------------

**Section III (Continued)**

**D. Maintenance and Implementation Activities for the Interagency
Coordinating Council (ICC)**

> When completing this section include:

-   A description of the nature and scope of each major activity to be
    carried out under Part C in maintaining and implementing the
    statewide system of early intervention services. Activities could
    include coordinating child find identification efforts, ensuring the
    timely provision and payment of early intervention services to
    eligible children and their families, advising on early childhood
    transition, support for the ICC (travel), or other implementation
    and development activities of the SICC;

-   The approximate amount of funds to be spent for each activity; and

-   A subtotal of the amount.

> *(Add columns and rows as needed.)*

  ----------------- ----------- ------------------------------------------
  **Major           **Part C    **Description of Activities**
  Activity**        Funds to be 
                    Spent**     

                                

                                

                                

                                

  **Subtotal of                 
  amount under D:**             
  ----------------- ----------- ------------------------------------------

## Section III (Continued)

## E. Direct Services (Funded by Part C Federal Dollars)

> When completing this section include:

-   A description of any direct early intervention service that the
    State lead agency expects to provide to eligible children and their
    families with funds under this part, including a description of any
    services provided to at-risk infants and toddlers and their families
    for States that provide services to at-risk children as part of its
    eligibility criteria. The description must include information about
    each type of service to be provided, including:

    -   A summary of the methods to be used to provide the service
        (e.g., contracts or other arrangements with specified public or
        private organizations); and

    -   The approximate amount of funds under this part to be used for
        the direct provision of early intervention services.

> Provide subtotals of the amount and for salaries and fringe benefits
> for direct service employees (discipline). *(Add columns and rows as
> needed.)*

  ----------------- ----------- ------------------------------------------
  **Direct          **Part C    **Summary of Methods to be Used to Provide
  Service**         Funds to be Service**
                    Spent**     

                                

                                

                                

  **Subtotal of                 
  amount under E:**             
  ----------------- ----------- ------------------------------------------

+-----------+-------+-----+-------------------------------------------+
| **Direct  | **S   | **% | ####### Description of Duties             |
| Service   | alary | P   |                                           |
| Employees | and   | art |                                           |
| (Disc     | Fri   | C** |                                           |
| ipline)** | nge** |     |                                           |
+-----------+-------+-----+-------------------------------------------+
|           |       |     |                                           |
+-----------+-------+-----+-------------------------------------------+
| **Sub     |       |     |                                           |
| Total**:  |       |     |                                           |
+-----------+-------+-----+-------------------------------------------+

**Section III (Continued)**

**F. Description of Optional Use of Part C Funds (For States that Do Not
Provide Direct Service for At-Risk Infants and Toddlers)**

> For any State that does not provide direct services for at-risk
> infants and toddlers under 20 U.S.C. 1437(a)(4), but chooses to use
> funds under 20 U.S.C. 1438(5), each Application must include a
> description of how these funds will be used. Specifically, a State may
> use Part C funds for initiating, expanding, or improving collaborative
> efforts related to at-risk infants and toddlers, including
> establishing linkages with appropriate public or private
> community-based organizations, services, or personnel for the purpose
> of:

-   Identifying and evaluating at-risk infants and toddlers;

-   Making referrals of at-risk infants and toddlers who are identified
    and evaluated; and

-   Conducting periodic follow-up on at-risk infants and toddlers to
    determine if the status of the infant or toddler's eligibility for
    Part C services has changed.

> Provide a subtotal of the amount. *(Add columns and rows as needed.)*

  ----------------------------------------------------------- -----------
  **Description of Activity**                                 **Amount of
                                                              Funds**

                                                              

                                                              

                                                              

                                                              

  **Subtotal of amount under F:**                             
  ----------------------------------------------------------- -----------

## Section III (Continued)

## G. Activities by Other Agencies

> If other State or local public agencies are to receive a portion of
> the Federal funds under Part C, the Application must include:

-   The name of each public agency expected to receive funds;

-   The approximate amount of funds each public agency will receive; and

-   A summary of the purposes for which the funds will be used.

> Provide subtotal of amount. *(Add columns and rows as needed.)*

  -------------------- -------------- -----------------------------------
  **Agency Receiving   **Amount of    **Purpose**
  Funds**              Funds**        

                                      

                                      

                                      

                                      

  **Subtotal of amount                
  under G:**                          
  -------------------- -------------- -----------------------------------

## Section III (Continued)

## H. Totals

> **Enter the subtotal amounts for Sub Sections A-G found in Section III
> and any indirect costs charged as specified in Section IV.B. The sub
> total amounts (Rows 1-8) should total the estimated grant application
> amount. (A State may apply for less than the full estimated allotted
> amount.)**

  --------------- ------------- --------------------------------------------------
  Enter the                     
  subtotal                      
  amounts for Sub               
  Sections A-G                  
  found in                      
  Section III of                
  this                          
  application.                  

  **Row No.**     **Section**   **Amount**

  1\.             III.A.        \$

  2\.             III.B.        \$

  3\.             III.C.        \$

  4\.             III.D.        \$

  5\.             III.E.\       \$
                  *(Direct      
                  Service)*     

                  III.E.\       \$
                  *(Direct      
                  Service       
                  Employees)*   

  6\.             III.F.        \$

  7\.             III.G.        \$

  Enter any                     
  Indirect Costs                
  Charged (See                  
  Section IV.B of               
  this                          
  application.)                 

  8\.             IV.B          \$

  **Total** (Rows               \$
  1-8)                          
  --------------- ------------- --------------------------------------------------

### Section IV

**A. System of Payments / Use of Insurance / Program Income**

The State

\_\_\_\_\_ does (check as applicable)

\_\_\_\_\_ does not (check as applicable)

have a system of payments for Part C services under 20 U.S.C. 1432(4)(B)
which may include use of public and/or private insurance or family fees,
such as a sliding scale. Any family fees are treated as \'program
income\' for purposes of 34 CFR §80.25 and are not included in the
State\'s determination of State and local expenditures for purposes of
20 U.S.C. 1437(b)(5)(B). *Note: If the State has adopted new or has
revised its existing policies and procedures regarding its system of
payments, it must submit these new and/or revised policies and
procedures under Item 7 in Section II.A above.*

### B. Restricted Indirect Cost Rate/Cost Allocation Plan Information

(*Note: To be completed if Lead Agency is not a State Educational
Agency.)*

[If the lead agency is not a State educational agency]{.underline} (as
well as any outlying areas that have the Department of Interior as its
cognizant Federal agency, even if an SEA) check the applicable status
below (more than one check mark may be necessary) and enclose
appropriate documentation for this Federal Fiscal Year.

\_\_\_\_\_ The lead agency has a final restricted indirect cost rate or
cost allocation plan that has been approved by the State lead agency\'s
cognizant Federal agency and is in effect for this Federal fiscal year
(FFY) (ending on June 30, 2010). (Attach a copy of the approved
restricted indirect cost rate agreement or cost allocation plan.)

\_\_\_\_\_ The lead agency has either a provisional or final restricted
indirect cost rate or cost allocation plan that expires or expired on
\_\_\_\_\_\_\_\_\_ and the State is in the process of negotiating a new
restricted indirect cost rate agreement or cost allocation plan that
will be in effect for the period
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.[^2] The State lead agency will
continue to charge or bill the Part C grant using the provisional or
previously approved final restricted indirect cost rate or cost
allocation plan until a new rate or plan is negotiated and approved by
the State\'s cognizant Federal agency, at which point the State lead
agency must make appropriate adjustments for applicable FFYs. The State
acknowledges that a final restricted indirect cost rate may result in an
adjustment of the final audited expenditures allowable to be charged to
the Part C grant and the Department\'s approval of this FFY Part C
application with an expired or provisional restricted indirect cost rate
does not constitute approval of that rate as the final rate for the lead
agency for this FFY. When a final restricted indirect cost rate is
approved, the lead agency must submit to OSEP: (1) a copy of the
\"final\" restricted indirect cost rate agreement; and (2) details of
adjustments made to past GAPS draw downs in light of the \"final\" rate.
(Attach a copy of the previously approved restricted indirect cost rate
agreement or cost allocation plan.)

\_\_\_\_\_ No indirect costs are charged to the Part C grant. The total
amount of the Federal Part C grant is used for allowable direct costs.

\_\_\_\_\_ Other, explanation attached.

[^1]: If Option 2 is checked, the State is to provide dates in Sections
    II.A and II.B as to when the required policies, procedures, methods,
    descriptions, and assurances will be provided, which date can be no
    later than June 30, 2010. The State will be granted conditional
    approval until it can provide all policies, procedures, methods,
    descriptions, and assurances.

[^2]: A \"provisional\" indirect cost rate is a temporary rate
    established for a future prospective period of time to permit
    budgeting, obligations, and payment of funds by awarding agencies
    until such time as the actual indirect costs can be determined and a
    final rate is established for the applicable period; provisional
    rates are subject to adjustment by issuance of a \"final\" rate
    based on actual indirect costs incurred for the period (usually the
    organization\'s fiscal year).