Instruction Sheet for Part C Annual State Application: FFY 201 5 Instruction Sheet - 1

OMB No. 1820 - 0550/Expiration Date: **An nual State A** **pplication Under Part C of the Individuals with Disabilities Education A** **ct As A** **mended in 2004, and the Final IDEA Part C Regulations Published on September 28, 2011**  **Instruction Sheet 1**  **Section I** A. Subm ission Statement for Part C in IDEA Wh en com pleting this section:  Select and check the appropriate submission statement(s) the State is using for this Federal Fiscal Year (FFY). The third statement is optional and should only be checked if the State chooses to submit policies and procedures to O SEP for review under one or more of the conditions specified in the statement . Possible combinations of ‘checked’ statements are as follows: 1; 2; 1 and 3; or 2 and 3. B. Conditional Approval for FFY 201 4 Year Section I.B is to be completed only if the State received **conditional approval** for the FFY 201 4 grant ye ar. Wh en com pleting this section:  Check only one of the statements provided under 1 and/or 2.  The State must follow the directions found in the parenthetical phrases if 1a, 2b or 2c is checked. **Se ction II**  A. State Policies, Procedures and Descriptions Wh en com pleting this section:  Read each statement (Policies and Procedures; Descriptions)

. 2  Enter, in the cells found to the left of the statements, either a check in one of the cells labeled **N** (for n ew policies, procedures or descriptions), **R** (for revised policies, procedures or descriptions), or **OF** (for “on file” with OSEP) found in the ‘ **yes** ’ column or a **date** in the cell found in the ‘ **no’** column. If the cell labeled N or R is checked, the State must submit those policies, procedures or descriptions with the FFY 201 5 application. The date in the ‘no’ column is the date by which the State will submit to OSEP required documentation and which date can be no later than June 30, 201 6

. At least one cell m ust be completed beside each statement

.  Enter ‘NA’ in the cells to the left of the Optional Policies, Procedures or Descriptions if the provision is not applicable to your State. B. Assurances and Optional Assurance Wh en com pleting this section:  Read each assurance.  Enter, in the cells found to the left of the assurance, either a check in the cell found in the ‘yes’ column or a **date** in the cell found in the ‘no’ column. The date in the ‘no’ column is the date by which the State will complete changes in ord er to provide the assurance and which date can be no later than June 30, 201 6

. At least one cell must be completed beside each assurance

.  Enter ‘NA’ in the cells to the left of the Optional Assurance if this assurance is not applicable. C. Certifications Wh en com pleting this section:  Read each certification statement and place a c heck in the cells labeled ‘yes.’  The State must be able to certify financial responsibility consistent with 34 CFR §303.202. D. Statement To complete the assurance and certificati on statement:  Enter the name of the State and official name of the State Agency in the appropriate blanks.  Print the name and title of the authorized representative of the State.  Sign the signature block.  Enter the date the assurance and certification stat em ent was signed.

1 Grayed out cells indicate that a response in that cell is not possible. 2 The Technical Assistance Checklists are located at http://www.ed.gov/fund/grant/apply/osep/2014apps.html . Th ese ch ecklists are provided to assist States in the completion of OMB Information Collection 1820 - 0550.Instruction Sheet for Part C Annual State Application: FFY 201 5 Instruction Sheet - 2

OMB No. 1820 - 0550/Expiration Date: **Section III** Each State’s Application must include a description of how a State proposes to use its funds under Part C. The description must be presented separately for the lead agency and the State Interagency Coordinating Council (SICC) . States with a fully approved FFY 201 4 Application must still submit any appropriate revisions to the ‘Description of Use of Part C Funds.’ Please also be sure to mark “N” for “New” under Section II.A.6 of the Application. States should follow the inst ructions and use the forms in Section III

. A. Description of Use of Part C Funds for the Lead Agency Wh en com pleting this section include:  Totals for the number of lead agency administrative positions, salaries and fringe benefits funded either 100 percen t 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 under Section A. Identify any administrative positions for which less than 100% of the time is spent on Part C a nd, 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. Please note that Lead Agencies that are State Education Agencies (SEAs), are not requ ired to provide the detailed information in the first two bullets above, but must provide the subtotal amount to be used under Section III.A (as noted in the third bullet above). B. Maintenance and Implementation Activities for the Lead Agenc y Wh en com plet ing this section include:

 A description of the nature and scope of each major activity to be carried out under Part C in ma intaining 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 under Sectio n B. C. Description of Use of Part C Funds for the State Interagency Coordinating Council ( S ICC) Wh en com pleting this section include:  Totals for the number of S ICC administrative positions, salaries and fringe benefits funded either 100 percent and/or les s than 100 percent with Part C funds;  A general description of the duties which the positions entail; and  A subtotal of the amount under Section C. 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. D. Maintenance and Implementation Activities for the State Interagency Coordinating Council (SICC) Wh en com pleting this section include:

 A description of the nature and scope of each major activity to be carried out under Part C in ma intaining and implementing the statewide system of early intervention services. Activities could include coordinating c hild find identification efforts, ensuring the timely provision and payme nt of early intervention services to eligible children and their families, advising on early childhood transition, support for the S ICC (travel), or other implementation and developme nt activities of the SICC;  The approximate amount of funds to be spent for each activity; and  A subtotal of the amount under Section D. E. Direct Services Wh en com pleting 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. The description must include information about each type of service to be provided, including:Instruction Sheet for Part C Annual State Application: FFY 201 5 Instruction Sheet - 3

OMB No. 1820 - 0550/Expiration Date:  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 (by each direct service) of funds under this part to be used for the direct provision of early intervention services. Provide subtotals of the amount under Section E and for salaries and fringe benefits for direct service em ployees (discipline). F. Description of Optional Use of Part C Funds 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 t o 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- ris k 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 u nder Section F. G. Activities by Other State or Local Public 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 agenc y will receive; and  A summary of the purposes for which the funds will be used. Provide a subtotal of the amount under Section G. H. Totals Enter the subtotal amounts for Sub Sections A- G found in Section III and enter in row 8 any indirect costs to be charged to the State’s FFY 201 4 Part C funds based on the information and documentation provided by the State in Section IV.B

. The subtotal amounts (Rows 1 - 8 ) should total the estimated grant application amo unt. (A State may apply for less than the full estimated allotted amount.) **Section IV** A. System of Payme nts / Use of Insurance / Program Income Wh en com pleting this section:

 Place a check in one of the two blanks provided. By entering a check in the appropriate blank the State is indicating whether the State is required to have a written system of payme nts policy for Part C services under 34 CFR §§ 303.203(b)(1), 303.500(b), 303.520 , and 303.521 . The State is required to have a policy if the State use s pub lic insurance or benefits, private insurance or family fees, such as a sliding scale, to pay for Part C services. Such a polic y m ust be in writing, subjected to the public participation requirements in 34 CFR §303.208(b); on file with OSEP , and reflected in the State’s response under Section II.A of the Application. If the State has adopted new or has revised its existing policies and procedures regarding its system of payme nts, it must submit these policies and procedures under Section II of the Applicati on unless those documents were previously submitted and approved by OSEP

. B. Restricted Indirect Cost Rate/Cost Allocation Plan Information Lead agencies that are not State educational agencies (SEAs) (as well as any outlying areas that have the Department of Interior as its cognizant Federal agency, even if an SEA) must complete the requested information on indirect costs in Appendix A, Part III of the Application and submit the required documentation. Because the IDEA (20 U.S.C. 1437(b)(5)(B)) has a stat utory requirement that prohibits the use of Federal Part C funds to supplant non - Federal funds, the Education Department General Adm inistration Regulations (EDGAR), at 34 CFR §§76.56 0 - 76.569, require that Part C lead agencies use an approved restricted ind irect cost rate or cost allocation plan for the Part C program. The costInstruction Sheet for Part C Annual State Application: FFY 201 5 Instruction Sheet - 4

OMB No. 1820 - 0550/Expiration Date: principles contained in the Office of Management and Budget (OMB) Circular A- 87 also apply. (Refer to OSEP Memorandum 99 - 2 for additional information.) States must also submit with the Application documentation that the Part C lead agency has an approved final restricted indirect cost rate agreement or cost allocation plan for the Part C program that is applicable for FFY 201 5 (effective July 1, 201 5 through June 30, 201 6 )

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