Instruction Sheet for Part C Annual State Application: FFY 2015 Instruction Sheet - 1

OMB No. 1820-0550/Expiration Date: 

Annual State Application Under Part C of the Individuals with Disabilities Education Act

As Amended in 2004, and the Final IDEA Part C Regulations Published on September 28, 2011

Instruction Sheet1

Section I

A. Submission Statement for Part C in IDEA

When completing 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 OSEP 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 2014 Year

Section I.B is to be completed only if the State received conditional approval for the FFY 2014 grant 

year.

When completing 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.

Section II

A. State Policies, Procedures and Descriptions

When completing 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 

new 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 2015 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, 2016. At least one 

cell must 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

When completing 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 order to provide the assurance and which date can be no 

later than June 30, 2016. 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

When completing this section:

 Read each certification statement and place a check 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 certification 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 statement 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. These checklists are

provided to assist States in the completion of OMB Information Collection 1820-0550. 
Instruction Sheet for Part C Annual State Application: FFY 2015 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 2014 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 instructions and use the forms in 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 under Section A.

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. Please note that Lead Agencies that are State 

Education Agencies (SEAs), are not required 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 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 under Section B.

C. Description of Use of Part C Funds for the State Interagency Coordinating Council (SICC)

When completing this section include:

 Totals for the number of SICC 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 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)

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 SICC (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 under Section D.

E. Direct Services

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. The description must include 

information about each type of service to be provided, including:
Instruction Sheet for Part C Annual State Application: FFY 2015 Instruction Sheet - 3

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 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 

employees (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 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 under 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 agency 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 2014 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 amount. (A State may apply for less than the full estimated allotted amount.)

Section IV

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

When completing 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 payments 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 uses public insurance or benefits, private insurance or family fees, such 

as a sliding scale, to pay for Part C services. Such a policy must 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 payments, it must submit these policies and procedures under Section II of the Application 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 statutory requirement that prohibits 

the use of Federal Part C funds to supplant non-Federal funds, the Education Department General 

Administration Regulations (EDGAR), at 34 CFR §§76.560-76.569, require that Part C lead agencies 

use an approved restricted indirect cost rate or cost allocation plan for the Part C program. The cost 
Instruction Sheet for Part C Annual State Application: FFY 2015 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 2015 (effective July 1, 2015

through June 30, 2016).