OMB NO. 1820-0550

Expires: 

ANNUAL STATE APPLICATION UNDER PART C OF THE

INDIVIDUALS WITH DISABILITIES EDUCATION ACT AS AMENDED IN 2004

FEDERAL FISCAL YEAR (FFY) 2015

CFDA No. 84.181A

ED FORM No. 1 B20--26P

UNITED STATES DEPARTMENT OF EDUCATION

OFFICE OF SPECIAL EDUCATION PROGRAMS

Washington, DC 20202-2600

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of 

information unless such collection displays a valid OMB control number. Public reporting burden for this 

collection of information is estimated to average 10 hours per response, including time for reviewing 

instructions, searching existing data sources, gathering and maintaining the data needed, and completing 

and reviewing the collection of information. The obligation to respond to this collection is required to 

obtain or retain benefits (20 U.S.C. 1433; 20 U.S.C. 1435). Send comments regarding the burden 

estimate or any other aspect of this collection of information, including suggestions for reducing this 

burden, to the U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20210-4537 or 

email ICDocketMgr@ed.gov and reference the OMB Control Number 1820-0550. Note: Please do not 

return the completed Annual State Application form to this address.
__________________

State

Part C Annual State Application: FFY 2015 Section I -1

OMB No. 1820-0550/Expiration Date

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, certifications, and assurances meet 

all application requirements of Part C of the Act as found in the Individuals with Disabilities 

Education Act (IDEA), codified at 20 U.S.C. 1431 through 1443 and the Part C regulations 

in 34 CFR Part 303. 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 either has on file with the Secretary or has 

submitted new or revised State policies, procedures, methods, and descriptions that meet 

all requirements found in Section II.A.

2. _____ The State cannot provide the policies, procedures, methods, descriptions, and/or 

assurances for all application requirements of Part C of the Act as found in Part C of the 

IDEA, 20 U.S.C. 1431 through 1443 and the Part C regulations in 34 CFR Part 303. The 

State has determined that it is unable to provide the policies, procedures, methods, 

descriptions, and/or assurances that are checked 'No' in Sections II.A and II.B. However, 

the State assures that throughout the period of this grant award the State will operate 

consistent with all requirements of IDEA in 20 U.S.C. 1431 through 1443 and the final Part 

C regulations in 34 CFR Part 303. 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 Part C Act and regulations, as amended, as soon as possible, 

and not later than June 30, 2016. 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’ in Section II.A are enclosed with this 

application as revised or new or are identified as “OF” already on file with the Secretary.

1

Optional:

3. _____ The State is submitting new or modified State policies and procedures previously submitted 

to the Department and checked in Section II.A, “N”, “R” or “OF” cell(s) found in the 'Yes' 

column. These modifications are a result of: (1) the State revising its applicable State law or 

regulations; (2) changes required by the Secretary due to 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 statement(s) below:

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

_____ a. Sections II.A and II.B reflect completion of all issues identified in the FFY 2014 conditional 

approval letter (attach any additional documentation required by the FFY 2014 letter).

_____ b. As noted in Sections II.A and II.B, the State has not completed all issues identified in the 

FFY 2014 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 2014 conditional approval letter.

_____ b. The State is attaching documentation of completion of all issues identified in the FFY 

2014 conditional approval letter. (Attach documentation showing completion of all issues.)

_____ c. The State has not completed all issues identified in the FFY 2014 conditional approval 

letter. (Attach documentation showing completion of any issues and a list of items not yet completed.)

 

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, 2016. 
__________________

State

Part C Annual State Application: FFY 2015 Section II -2

OMB No. 1820-0550/Expiration Date: 

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 the Individuals with Disabilities Education Act (IDEA or Act) in 20 U.S.C. 1431 - 1443 

and the final Part C regulations in 34 CFR Part 303 (Part C). By submission of this Section II, the State 

assures that throughout the period of this FFY 2014 grant award, the State will operate consistent with all 

requirements of Part C of the IDEA in 20 U.S.C. 1431 through 1443 and the final Part C regulations in 34 

CFR Part 303. 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 Part C Act and final 

regulations by the date indicated below and not later than June 30, 2016.

Check and enter date(s) as applicable. 

Enclose relevant documents.

N = 'New' Policy and/or Procedure

R = 'Revised' Policy and/or Procedure

OF = Policy and/or Procedure is already 'On File' with the USDE

Yes

(If New or Revised is 

checked, the State is 

submitting policies, 

procedures, methods, 

and descriptions with this 

application. If already 

'On File with OSEP', 

check OF.)

No

(Policies, 

procedures, 

methods, and 

descriptions have 

not been 

provided. 

Provide date by 

which State will 

submit to OSEP 

required 

documentation, 

which date shall 

be no later than 

June 30, 2016.)

N R OF State Policies, Procedures, Methods, and Descriptions

Subpart C – State Policies and Procedures

1. Each application must include the name of the State 

lead agency, as designated under §303.120, that will 

be responsible for the administration of funds provided 

under this part. (34 CFR §303.201)

2. Each application must include a description of 

services to be provided under Part C to infants and 

toddlers with disabilities and their families through the 

State’s system. (34 CFR §303.203(a))

3. Each application must include the State’s policies and 

procedures regarding the identification and 

coordination of all available resources within the State 

from Federal, State, local, and private sources as 

required under subpart F of 34 CFR Part 303.

The State must have policies and procedures that 

meet the requirements listed in 3(a) and the methods 

identified in 3(b), and must provide responses to those 
__________________

State

Part C Annual State Application: FFY 2015 Section II -3

OMB No. 1820-0550/Expiration Date: 

Check and enter date(s) as applicable. 

Enclose relevant documents.

N = 'New' Policy and/or Procedure

R = 'Revised' Policy and/or Procedure

OF = Policy and/or Procedure is already 'On File' with the USDE

Yes

(If New or Revised is 

checked, the State is 

submitting policies, 

procedures, methods, 

and descriptions with this 

application. If already 

'On File with OSEP', 

check OF.)

No

(Policies, 

procedures, 

methods, and 

descriptions have 

not been 

provided. 

Provide date by 

which State will 

submit to OSEP 

required 

documentation, 

which date shall 

be no later than 

June 30, 2016.)

N R OF State Policies, Procedures, Methods, and Descriptions

entries. If the State has not adopted a system of 

payments, it may respond “NA” to 3(a). 

(a) If the State has adopted a system of payments, 

each application must include any policies or 

procedures adopted by the State as its system of 

payments and those policies and procedures 

must meet the requirements in §§303.510, 

303.520 and 303.521 (regarding the use of public 

insurance or benefits, private insurance, or family

costs or fees). 

(34 CFR §303.203(b)(1))

The policies and procedures listed in 3(a) are 

optional. Enter 'NA' in the cells to the left if the 

State has elected not to adopt a system of 

payments (which includes a system to use public 

insurance or benefits or private insurance or

family fees to pay for Part C services); otherwise 

check the appropriate response under the 'Yes' 

column and, if checking ‘N’ or ‘R’, attach policies 

and procedures.

The State’s response under 3(a) of Section II.A 

must match the State’s response under Section 

IV.A.

(b) Each application must include the methods (State 

law, regulation, signed interagency or intraagency agreements or other appropriate written 

method(s) approved by the Secretary) used by 

the State to implement the payor of last resort 

and fiscal responsibility requirements in 

§303.511(b)(2) and (3). 

(34 CFR §303.203(b)(2))

If the State uses signed interagency agreements 

or “other appropriate written method(s)” to meet 
__________________

State

Part C Annual State Application: FFY 2015 Section II -4

OMB No. 1820-0550/Expiration Date: 

Check and enter date(s) as applicable. 

Enclose relevant documents.

N = 'New' Policy and/or Procedure

R = 'Revised' Policy and/or Procedure

OF = Policy and/or Procedure is already 'On File' with the USDE

Yes

(If New or Revised is 

checked, the State is 

submitting policies, 

procedures, methods, 

and descriptions with this 

application. If already 

'On File with OSEP', 

check OF.)

No

(Policies, 

procedures, 

methods, and 

descriptions have 

not been 

provided. 

Provide date by 

which State will 

submit to OSEP 

required 

documentation, 

which date shall 

be no later than 

June 30, 2016.)

N R OF State Policies, Procedures, Methods, and Descriptions

the requirements in 3(b), please check ‘N’ or ‘R’ 

and submit with the application. If the State’s 

method is a State statute or regulation, the State 

does not need to submit that method (the statute 

or regulation) with its application.

4. Each application must include the State’s rigorous 

definition of developmental delay as required under 

§§303.10 and 303.111. Each Statewide system must 

include the State's rigorous definition of 

developmental delay, consistent with §§303.10 and 

303.203(c), that will be used by the State in carrying 

out programs under Part C of the Act in order to 

appropriately identify infants and toddlers with 

disabilities who are in need of services under Part C 

of the Act. The definition must-- 

(a) Describe, for each of the areas listed in 

§303.21(a)(1), the evaluation and assessment 

procedures, consistent with §303.321, that will be 

used to measure a child's development; and 

(b) Specify the level of developmental delay in 

functioning or other comparable criteria that 

constitute a developmental delay in one or more 

of the developmental areas identified in 

§303.21(a)(1). 

(34 CFR §§303.203(c) & 303.111)

5. If the State provides services under Part C to at-risk 

infants and toddlers through the statewide system, the 

application must include--

(a) The State’s definition of at-risk infants and 

toddlers with disabilities who are eligible in the 

State for services under Part C (consistent with 

§§303.5 and 303.21(b)); and

(b) A description of the early intervention services 
__________________

State

Part C Annual State Application: FFY 2015 Section II -5

OMB No. 1820-0550/Expiration Date: 

Check and enter date(s) as applicable. 

Enclose relevant documents.

N = 'New' Policy and/or Procedure

R = 'Revised' Policy and/or Procedure

OF = Policy and/or Procedure is already 'On File' with the USDE

Yes

(If New or Revised is 

checked, the State is 

submitting policies, 

procedures, methods, 

and descriptions with this 

application. If already 

'On File with OSEP', 

check OF.)

No

(Policies, 

procedures, 

methods, and 

descriptions have 

not been 

provided. 

Provide date by 

which State will 

submit to OSEP 

required 

documentation, 

which date shall 

be no later than 

June 30, 2016.)

N R OF State Policies, Procedures, Methods, and Descriptions

provided under Part C to at-risk infants and 

toddlers with disabilities who meet the State’s 

definition described in §303.204(a). 

(34 CFR §303.204).

The policies and procedures listed in 5 are 

optional (i.e., they only apply if the State opts to 

serve at-risk children). Enter 'NA' in the cells to 

the left if the State has elected not to provide 

services under Part C to at-risk infants and 

toddlers; otherwise check the appropriate 

response under the 'Yes' column and, if checking 

‘N’ or ‘R’, attach the definition and description.

6. Each State application must include a description of 

the State’s use of funds under Part C for the fiscal 

year or years covered by the application. The 

description must be presented separately for the lead 

agency and the State Interagency Coordinating 

Council (Council), and include the information required 

in attached Section III of this application. (34 CFR 

§303.205) 

7. Each application must include the State’s policies and 

procedures that require the referral for early 

intervention services under Part C of specific children 

under the age of three, as described in §303.303(b)

(which includes children who are the subject of a 

substantiated case of abuse or neglect, or directly 

affected by illegal substance abuse or withdrawal 

symptoms resulting from prenatal drug exposure). (34 

CFR §303.206)

8. Each application must include a description of the 

procedure used by the State to ensure that resources 

are made available under Part C for all geographic 

areas within the State. (34 CFR §303.207)
__________________

State

Part C Annual State Application: FFY 2015 Section II -6

OMB No. 1820-0550/Expiration Date: 

Check and enter date(s) as applicable. 

Enclose relevant documents.

N = 'New' Policy and/or Procedure

R = 'Revised' Policy and/or Procedure

OF = Policy and/or Procedure is already 'On File' with the USDE

Yes

(If New or Revised is 

checked, the State is 

submitting policies, 

procedures, methods, 

and descriptions with this 

application. If already 

'On File with OSEP', 

check OF.)

No

(Policies, 

procedures, 

methods, and 

descriptions have 

not been 

provided. 

Provide date by 

which State will 

submit to OSEP 

required 

documentation, 

which date shall 

be no later than 

June 30, 2016.)

N R OF State Policies, Procedures, Methods, and Descriptions

9. Each application must include a description of the 

policies and procedures used by the State to ensure 

that, before adopting any new policy or procedure 

(including any revision to an existing policy or 

procedure) needed to comply with Part C of the Act 

and 34 CFR Part 303, the lead agency--

(1) Holds public hearings on the new policy or 

procedure (including any revision to an 

existing policy or procedure);

(2) Provides notice of the hearings held in 

accordance with §303.208(b)(1) at least 30 

days before the hearings are conducted to 

enable public participation; and

(3) Provides an opportunity for the general 

public, including individuals with disabilities, 

parents of infants and toddlers with 

disabilities, EIS providers, and the members 

of the Council, to comment for at least 30 

days on the new policy or procedure 

(including any revision to an existing policy or 

procedure) needed to comply with Part C of 

the Act and 34 CFR Part 303. 

(34 CFR §303.208(b))

10. (a) Application Requirements: Each State must 

include the following in its application:

(1) A description of the policies and procedures it 

will use to ensure a smooth transition for 

infants and toddlers with disabilities under the 

age of three and their families from receiving 

early intervention services under Part C to 

preschool or other appropriate services (for 

toddlers with disabilities) or exiting the 

program for infants and toddlers with 

disabilities. 
__________________

State

Part C Annual State Application: FFY 2015 Section II -7

OMB No. 1820-0550/Expiration Date: 

Check and enter date(s) as applicable. 

Enclose relevant documents.

N = 'New' Policy and/or Procedure

R = 'Revised' Policy and/or Procedure

OF = Policy and/or Procedure is already 'On File' with the USDE

Yes

(If New or Revised is 

checked, the State is 

submitting policies, 

procedures, methods, 

and descriptions with this 

application. If already 

'On File with OSEP', 

check OF.)

No

(Policies, 

procedures, 

methods, and 

descriptions have 

not been 

provided. 

Provide date by 

which State will 

submit to OSEP 

required 

documentation, 

which date shall 

be no later than 

June 30, 2016.)

N R OF State Policies, Procedures, Methods, and Descriptions

(2) A description of how the State will meet each 

requirement in §303.209(b) through (f). 

(3) (i)(A) If the lead agency is not the SEA, an 

interagency agreement between the lead 

agency and the SEA; or (B) If the lead 

agency is the SEA, an intra-agency 

agreement between the program within that 

agency that administers Part C of the Act and 

the program within the agency that 

administers section 619 of the Act

(ii) To ensure a seamless transition between 

services under Part C and under Part B of the 

Act, an interagency agreement under 

paragraph (a)(3)(i)(A) of this section or an 

intra-agency agreement under paragraph 

(a)(3)(i)(B) of this section must address how 

the lead agency and the SEA will meet the 

requirements of paragraphs (b) through (f) of 

this section (including any policies adopted by 

the lead agency under §303.401(d) and (e)), 

§303.344(h), and 34 CFR 300.101(b), 

300.124, 300.321(f) and 300.323(b).

(4) Any policy the lead agency has adopted 

under §303.401(d) and (e).

(b) Notification to the SEA and appropriate LEA. The 

State must ensure that--

(1) Subject to paragraph (b)(4) of this section, not 

fewer than 90 days before the third birthday 

of the toddler with a disability if that toddler 

may be eligible for preschool services under 

Part B of the Act, the lead agency notifies the 

SEA and the LEA for the area in which the 

toddler resides that the toddler on his or her 

third birthday will reach the age of eligibility 

for services under Part B of the Act, as 

determined in accordance with State law; or

(2) Subject to paragraph (b)(4) of this section, if 
__________________

State

Part C Annual State Application: FFY 2015 Section II -8

OMB No. 1820-0550/Expiration Date: 

Check and enter date(s) as applicable. 

Enclose relevant documents.

N = 'New' Policy and/or Procedure

R = 'Revised' Policy and/or Procedure

OF = Policy and/or Procedure is already 'On File' with the USDE

Yes

(If New or Revised is 

checked, the State is 

submitting policies, 

procedures, methods, 

and descriptions with this 

application. If already 

'On File with OSEP', 

check OF.)

No

(Policies, 

procedures, 

methods, and 

descriptions have 

not been 

provided. 

Provide date by 

which State will 

submit to OSEP 

required 

documentation, 

which date shall 

be no later than 

June 30, 2016.)

N R OF State Policies, Procedures, Methods, and Descriptions

the lead agency determines that the toddler is 

eligible for early intervention services under 

Part C of the Act more than 45 but less than 

90 days before that toddler’s third birthday 

and if that toddler may be eligible for 

preschool services under Part B of the Act, 

the lead agency, as soon as possible after 

determining the child’s eligibility, notifies the 

SEA and the LEA for the area in which the 

toddler with a disability resides that the 

toddler on his or her third birthday will reach 

the age of eligibility for services under Part B 

of the Act, as determined in accordance with 

State law; or

(3) Subject to paragraph (b)(4) of this section, if a 

toddler is referred to the lead agency fewer 

than 45 days before that toddler’s third 

birthday and that toddler may be eligible for 

preschool services under Part B of the Act, 

the lead agency, with parental consent 

required under §303.414, refers the toddler to 

the SEA and the LEA for the area in which 

the toddler resides; but, the lead agency is 

not required to conduct an evaluation, 

assessment, or an initial IFSP meeting under 

these circumstances; 

(4) The notification required under paragraphs 

(b)(1), (2), and (3) of this section is consistent 

with any policy that the State has adopted, 

under §303.401(e), permitting a parent to 

object to disclosure of personally identifiable 

information.

(c) Conference to discuss services. The State must 

ensure that—

(1) If a toddler with a disability may be eligible 

for preschool services under Part B of the 

Act, the lead agency, with the approval of 
__________________

State

Part C Annual State Application: FFY 2015 Section II -9

OMB No. 1820-0550/Expiration Date: 

Check and enter date(s) as applicable. 

Enclose relevant documents.

N = 'New' Policy and/or Procedure

R = 'Revised' Policy and/or Procedure

OF = Policy and/or Procedure is already 'On File' with the USDE

Yes

(If New or Revised is 

checked, the State is 

submitting policies, 

procedures, methods, 

and descriptions with this 

application. If already 

'On File with OSEP', 

check OF.)

No

(Policies, 

procedures, 

methods, and 

descriptions have 

not been 

provided. 

Provide date by 

which State will 

submit to OSEP 

required 

documentation, 

which date shall 

be no later than 

June 30, 2016.)

N R OF State Policies, Procedures, Methods, and Descriptions

the family of the toddler, convenes a 

conference, among the lead agency, the 

family, and the LEA not fewer than 90 days--

and, at the discretion of all of the parties, not 

more than 9 months--before the toddler’s 

third birthday to discuss any services the 

toddler may receive under Part B of the Act.

(2) If a toddler with a disability is determined to 

not be potentially eligible for preschool 

services under Part B of the Act, the lead 

agency, with the approval of the family of 

that toddler, makes reasonable efforts to 

convene a conference among the lead 

agency, the family, and providers of other 

appropriate services for the toddler to 

discuss appropriate services that the toddler 

may receive.

(d) Transition plan. The State must ensure that for all 

toddlers with disabilities –

(1)(i) It reviews the program options for the 

toddler with a disability for the period from 

the toddler's third birthday through the 

remainder of the school year; and

(ii) Each family of a toddler with a 

disability who is served under Part C is 

included in the development of the 

transition plan required under this 

section and §303.344(h);

(2) It establishes a transition plan in the IFSP 

not fewer than 90 days--and, at the 

discretion of all of the parties, not more than 

9 months--before the toddler’s third birthday; 

and

(3) The transition plan in the IFSP includes, 

consistent with §303.344(h), as 

appropriate—

(i) Steps for the toddler with a disability 
__________________

State

Part C Annual State Application: FFY 2015 Section II -10

OMB No. 1820-0550/Expiration Date: 

Check and enter date(s) as applicable. 

Enclose relevant documents.

N = 'New' Policy and/or Procedure

R = 'Revised' Policy and/or Procedure

OF = Policy and/or Procedure is already 'On File' with the USDE

Yes

(If New or Revised is 

checked, the State is 

submitting policies, 

procedures, methods, 

and descriptions with this 

application. If already 

'On File with OSEP', 

check OF.)

No

(Policies, 

procedures, 

methods, and 

descriptions have 

not been 

provided. 

Provide date by 

which State will 

submit to OSEP 

required 

documentation, 

which date shall 

be no later than 

June 30, 2016.)

N R OF State Policies, Procedures, Methods, and Descriptions

and his or her family to exit from the 

Part C program; and

(ii) Any transition services that the IFSP 

Team identifies as needed by that 

toddler and his or her family. 

(e) Transition conference and plan meeting 

requirements. Any conference conducted under 

paragraph (c) of this section or meeting to develop 

the transition plan under paragraph (d) of this 

section (which conference and meeting may be 

combined into one meeting) must meet the 

requirements in §§303.342(d) and (e) and 

303.343(a).

(f) Applicability of transition requirements. 

(1) The transition requirements in paragraphs 

(b)(1) and (2), (c)(1), and (d) of this section apply 

to all toddlers with disabilities receiving services 

under this part before those toddlers turn age 

three, including any toddler with a disability under 

the age of three who is served by a State that 

offers services under §303.211. 

(2) In a State that offers services under §303.211, 

for toddlers with disabilities identified in paragraph 

(b)(1) of this section, the parent must be provided 

at the transition conference conducted under 

paragraph (c)(1) of this section: (i) An 

explanation, consistent with §303.211(b)(1)(ii), of 

the toddler’s options to continue to receive early 

intervention services under this part or preschool 

services under section 619 of the Act; (ii) The 

initial annual notice referenced in §303.211(b)(1). 

(3) For children with disabilities age three and 

older who receive services pursuant to §303.211, 

the State must ensure that it satisfies the separate 

transition requirements in §303.211(b)(6)(ii). 

(34 CFR §303.209)
__________________

State

Part C Annual State Application: FFY 2015 Section II -11

OMB No. 1820-0550/Expiration Date: 

Check and enter date(s) as applicable. 

Enclose relevant documents.

N = 'New' Policy and/or Procedure

R = 'Revised' Policy and/or Procedure

OF = Policy and/or Procedure is already 'On File' with the USDE

Yes

(If New or Revised is 

checked, the State is 

submitting policies, 

procedures, methods, 

and descriptions with this 

application. If already 

'On File with OSEP', 

check OF.)

No

(Policies, 

procedures, 

methods, and 

descriptions have 

not been 

provided. 

Provide date by 

which State will 

submit to OSEP 

required 

documentation, 

which date shall 

be no later than 

June 30, 2016.)

N R OF State Policies, Procedures, Methods, and Descriptions

11. Each application must contain a description of State 

efforts to promote collaboration among Head Start and 

Early Head Start programs under the Head Start Act 

(42 U.S.C. 9801, et seq., as amended), early 

education and child care programs, and services 

under Part C. (34 CFR §303.210)

12. Each application must include, as required by Section 

427 of the General Education Provisions Act (GEPA), 

a description of how 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. (34 CFR §303.212(a)) 

13. (a) (1) A State may elect to include in its application 

for a grant under Part C a State policy, developed and 

implemented jointly by the lead agency and the SEA, 

under which a parent of a child with a disability who is 

eligible for preschool services under section 619 of the 

Act and who previously received early intervention 

services under Part C, may choose the continuation of 

early intervention services under Part C for his or her 

child after the child turns three until the child enters, or 

is eligible under State law to enter, kindergarten or 

elementary school.

(2) A State that adopts the policy described in 

paragraph (a)(1) of this section may determine whether 

it applies to children with disabilities--

(i) From age three until the beginning of the 

school year following the child’s third 

birthday;

(ii) From age three until the beginning of the 

school year following the child’s fourth 

birthday; or

(iii) From age three until the beginning of the 

school year following the child’s fifth 
__________________

State

Part C Annual State Application: FFY 2015 Section II -12

OMB No. 1820-0550/Expiration Date: 

Check and enter date(s) as applicable. 

Enclose relevant documents.

N = 'New' Policy and/or Procedure

R = 'Revised' Policy and/or Procedure

OF = Policy and/or Procedure is already 'On File' with the USDE

Yes

(If New or Revised is 

checked, the State is 

submitting policies, 

procedures, methods, 

and descriptions with this 

application. If already 

'On File with OSEP', 

check OF.)

No

(Policies, 

procedures, 

methods, and 

descriptions have 

not been 

provided. 

Provide date by 

which State will 

submit to OSEP 

required 

documentation, 

which date shall 

be no later than 

June 30, 2016.)

N R OF State Policies, Procedures, Methods, and Descriptions

birthday.

(3) However, in no case may a State provide services

under this section beyond the age at which the child 

actually enrolls in, or is eligible under State law to 

enter, kindergarten or elementary school in the State.

(b) Requirements. If a State’s application for a grant 

under Part C includes the State policy described 

in paragraph (a) of this section, the system must 

ensure the following:

(1) Parents of children with disabilities who are 

eligible for services under section 619 of the 

Act and who previously received early 

intervention services under Part C will be

provided annual notice (the initial annual 

notice must be provided as set forth in 

§303.209(f)(2)(ii)) that contains--

(i) A description of the rights of the parents 

to elect to receive services pursuant to 

§303.211 or under Part B of the Act; and

(ii) An explanation of the differences 

between services provided pursuant to 

§303.211 and services provided under 

Part B of the Act, including--

(A) The types of services and the

locations at which the services are 

provided;

(B) The procedural safeguards that 

apply; and

(C) Possible costs (including the costs 

or fees to be charged to families as 

described in §§303.520 and 

303.521), if any, to parents; and

(2) Consistent with §303.344(d), services 

provided pursuant to §303.211 will include an 

educational component that promotes school 

readiness and incorporates preliteracy, 

language, and numeracy skills.
__________________

State

Part C Annual State Application: FFY 2015 Section II -13

OMB No. 1820-0550/Expiration Date: 

Check and enter date(s) as applicable. 

Enclose relevant documents.

N = 'New' Policy and/or Procedure

R = 'Revised' Policy and/or Procedure

OF = Policy and/or Procedure is already 'On File' with the USDE

Yes

(If New or Revised is 

checked, the State is 

submitting policies, 

procedures, methods, 

and descriptions with this 

application. If already 

'On File with OSEP', 

check OF.)

No

(Policies, 

procedures, 

methods, and 

descriptions have 

not been 

provided. 

Provide date by 

which State will 

submit to OSEP 

required 

documentation, 

which date shall 

be no later than 

June 30, 2016.)

N R OF State Policies, Procedures, Methods, and Descriptions

(3) The State policy ensures that any child 

served pursuant to this section has the right, 

at any time, to receive FAPE (as that term is 

defined at §303.15) under Part B of the Act 

instead of early intervention services under 

Part C of the Act under §303.211.

(4) The lead agency must continue to provide all 

early intervention services identified in the 

toddler with a disability’s IFSP under 

§303.344 (and consented to by the parent 

under §303.342(e)) beyond age three until 

that toddler’s initial eligibility determination 

under Part B of the Act is made under 34 

CFR §300.306. This provision does not 

apply if the LEA has requested parental 

consent for the initial evaluation under 

§300.300(a) and the parent has not provided 

that consent.

(5) The lead agency must obtain informed 

consent from the parent of any child with a 

disability for the continuation of early 

intervention services pursuant to this section 

for that child. Consent must be obtained 

before the child reaches three years of age, 

where practicable. 

(6)(i) For toddlers with disabilities under the age 

of three in a State that offers services under this 

section, the lead agency ensures that the 

transition requirements in §303.209(b)(1) and (2), 

(c)(1) and (d) are met. 

(ii) For toddlers with disabilities age three and 

older in a State that offers services under this 

section, the lead agency ensures a smooth 

transition from services under this section to 

preschool, kindergarten or elementary school by: 

(A) Providing the SEA and LEA where the child 

resides, consistent with any State policy adopted 
__________________

State

Part C Annual State Application: FFY 2015 Section II -14

OMB No. 1820-0550/Expiration Date: 

Check and enter date(s) as applicable. 

Enclose relevant documents.

N = 'New' Policy and/or Procedure

R = 'Revised' Policy and/or Procedure

OF = Policy and/or Procedure is already 'On File' with the USDE

Yes

(If New or Revised is 

checked, the State is 

submitting policies, 

procedures, methods, 

and descriptions with this 

application. If already 

'On File with OSEP', 

check OF.)

No

(Policies, 

procedures, 

methods, and 

descriptions have 

not been 

provided. 

Provide date by 

which State will 

submit to OSEP 

required 

documentation, 

which date shall 

be no later than 

June 30, 2016.)

N R OF State Policies, Procedures, Methods, and Descriptions

under §303.401(e), the information listed in 

§303.401(d)(1) not fewer than 90 days before the 

child will no longer be eligible under subsection 

(a)(2) of this section to receive early intervention 

services under this section; (B) With the approval 

of the parents of the child, convening a transition 

conference, among the lead agency, the parents, 

and the LEA, not fewer than 90 days--and, at the 

discretion of all parties, not more than 9 months--

before the child will no longer be eligible under 

subsection (a)(2) of this section to receive, or will 

no longer receive, early intervention services 

under this section, to discuss any services that the 

child may receive under Part B of the Act; and

(C) Establishing a transition plan in the IFSP not 

fewer than 90 days--and, at the discretion of all 

parties, not more than 9 months--before the child 

will no longer be eligible under subsection (a)(2) of 

this section to receive, or no longer receives, early

intervention services under this section.

(7) In States that adopt the option to make 

services under Part C available to children 

ages three and older pursuant to §303.211,

there will be a referral to the Part C system, 

dependent upon parental consent, of a child 

under the age of three who directly 

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, 42 U.S.C. 

10401, et seq.

(c) Reporting requirement. If a State includes in its 

application a State policy described in 

§303.211(a), the State must submit to the 

Secretary, in the State’s report under §303.124, 

the number and percentage of children with 

disabilities who are eligible for services under 
__________________

State

Part C Annual State Application: FFY 2015 Section II -15

OMB No. 1820-0550/Expiration Date: 

Check and enter date(s) as applicable. 

Enclose relevant documents.

N = 'New' Policy and/or Procedure

R = 'Revised' Policy and/or Procedure

OF = Policy and/or Procedure is already 'On File' with the USDE

Yes

(If New or Revised is 

checked, the State is 

submitting policies, 

procedures, methods, 

and descriptions with this 

application. If already 

'On File with OSEP', 

check OF.)

No

(Policies, 

procedures, 

methods, and 

descriptions have 

not been 

provided. 

Provide date by 

which State will 

submit to OSEP 

required 

documentation, 

which date shall 

be no later than 

June 30, 2016.)

N R OF State Policies, Procedures, Methods, and Descriptions

section 619 of the Act but whose parents choose 

for their children to continue to receive early 

intervention services under §303.211.

(d) Available funds. The State policy described in 

§303.211(a) must describe the funds--including 

an identification as Federal, State, or local funds--

that will be used to ensure that the option 

described in §303.211(a) is available to eligible 

children and families who provide the consent 

described in §303.211(b)(5), including fees, if 

any, to be charged to families as described in 

§§303.520 and 303.521.

(e) Rules of construction. (1) If a statewide system 

includes a State policy described in §303.211(a), 

a State that provides services in accordance with 

this section to a child with a disability who is 

eligible for services under section 619 of the Act 

will not be required to provide the child FAPE 

under Part B of the Act for the period of time in 

which the child is receiving services under 

§303.211.

(2) Nothing in this section may be construed to 

require a provider of services under Part C to 

provide a child served under Part C with 

FAPE.

(34 CFR §303.211)

The policies and procedures listed in 13 are 

optional. Enter 'NA' in the cells to the left if the 

State has elected not to develop and implement a 

policy under 34 CFR §303.211 to make Part C 

services to children beyond age three; otherwise 

check the appropriate response under the 'Yes' 

column and, if checking ‘N’ or ‘R’, attach policies 

and procedures.
__________________

State

Part C Annual State Application: FFY 2015 Section II -16

OMB No. 1820-0550/Expiration Date: 

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.; 34 CFR §§303.101-126; 303.220; 303.227)

Check and enter date(s) as 

applicable

Subpart B – Assurances

(20 U.S.C. 1434; 1435; and 1437(b); 34 CFR §§303.101-126; 303.220; 303.227)

Yes

(Assurance is 

hereby 

provided.)

No

(Assurance 

cannot be 

ensured. 

Provide date 

on which 

State will 

complete 

changes in 

order to 

provide 

assurance.)

1. The State has adopted a policy that appropriate early intervention 

services, as defined in 34 CFR §303.13, are available to all infants and 

toddlers with disabilities in the State and their families, including--

(a) Indian infants and toddlers with disabilities and their families 

residing on a reservation geographically located in the State;

(b) Infants and toddlers with disabilities who are homeless children 

and their families; and 

(c) Infants and toddlers with disabilities who are wards of the State.

(34 CFR §303.101(a))

2. The State has in effect a statewide system of early intervention services 

that meets the requirements of section 635 of the Act, including policies 

and procedures that address, at a minimum, the components required in 

34 CFR §§303.111 through 303.126. (34 CFR §303.101(a))

3. The State ensures that any State rules, regulations, policies and 

procedures relating to 34 CFR Part 303 conform to the purposes and 

requirements of 34 CFR Part 303. (34 CFR §303.102)

4. Each statewide system (system) must include, at a minimum, the 

components described in §§303.111 through 303.126. (34 CFR 

§303.110)

5. The State has a policy in effect that ensures that appropriate early 

intervention services are based on scientifically based research, to the 

extent practicable, and are available to all infants and toddlers with 

disabilities and their families, including—

(a) Indian infants and toddlers with disabilities and their families 

residing on a reservation geographically located in the State; and 

(b) Infants and toddlers with disabilities who are homeless children 

and their families. (34 CFR §303.112)
__________________

State

Part C Annual State Application: FFY 2015 Section II -17

OMB No. 1820-0550/Expiration Date: 

Check and enter date(s) as 

applicable

Subpart B – Assurances

(20 U.S.C. 1434; 1435; and 1437(b); 34 CFR §§303.101-126; 303.220; 303.227)

Yes

(Assurance is 

hereby 

provided.)

No

(Assurance 

cannot be 

ensured. 

Provide date 

on which 

State will 

complete 

changes in 

order to 

provide 

assurance.)

6. (a) The Statewide system ensures the performance of--

(1) A timely, comprehensive, multidisciplinary evaluation of the 

functioning of each infant or toddler with a disability in the 

State; and 

(2) A family-directed identification of the needs of the family of 

the infant or toddler to assist appropriately in the 

development of the infant or toddler.

(b) The evaluation and family-directed identification required in 

paragraph (a) of this section must meet the requirements of 34 

CFR §303.321.

(34 CFR §303.113)

7. The Statewide system ensures that, for each infant or toddler with a 

disability and his or her family in the State, an IFSP, as defined in 34 

CFR §303.20, is developed and implemented that meets the 

requirements of 34 CFR §§303.340 through 303.345 and that includes 

service coordination services, as defined in 34 CFR §303.34. (34 CFR 

§303.114)

8. The Statewide system includes a comprehensive child find system that 

meets the requirements in 34 CFR §§303.302 and 303.303. (34 CFR 

§303.115)

9. The Statewide system includes a public awareness program that--

(a) Focuses on the early identification of infants and toddlers with 

disabilities; and

(b) Provides information to parents of infants and toddlers through 

primary referral sources in accordance with 34 CFR §303.301. 

(34 CFR §303.116)

10. The Statewide system includes a central directory that is accessible to 

the general public (i.e., through the lead agency’s Web site and other 

appropriate means) and includes accurate, up-to-date information about:

(a) Public and private early intervention services, resources, and 

experts available in the State; 

(b) Professional and other groups (including parent support and 

training and information centers, such as those funded under the 

Act) that provide assistance to infants and toddlers with disabilities 
__________________

State

Part C Annual State Application: FFY 2015 Section II -18

OMB No. 1820-0550/Expiration Date: 

Check and enter date(s) as 

applicable

Subpart B – Assurances

(20 U.S.C. 1434; 1435; and 1437(b); 34 CFR §§303.101-126; 303.220; 303.227)

Yes

(Assurance is 

hereby 

provided.)

No

(Assurance 

cannot be 

ensured. 

Provide date 

on which 

State will 

complete 

changes in 

order to 

provide 

assurance.)

eligible under Part C of the Act and their families; and 

(c) Research and demonstration projects being conducted in the State 

relating to infants and toddlers with disabilities.

(34 CFR §303.117)

11. The Statewide system includes 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. The State’s comprehensive 

system of personnel development--

(a) Includes--

(1) Training personnel to implement innovative strategies and 

activities for the recruitment and retention of EIS providers;

(2) Promoting the preparation of EIS providers who are fully and 

appropriately qualified to provide early intervention services 

under Part C; and

(3) Training personnel to coordinate transition services for 

infants and toddlers with disabilities who are transitioning 

from an early intervention services program under Part C of 

the Act to a preschool program under section 619 of the Act, 

Head Start, Early Head Start, an elementary school program 

under Part B of the Act, or another appropriate program.

(b) May include-- 

(1) Training personnel to work in rural and inner-city areas; 

(2) Training personnel in the emotional and social development 

of young children;

(3) Training personnel to support families in participating fully in 

the development and implementation of the child’s IFSP; 

and 

(4) Training personnel who provide services under this part 

using standards that are consistent with early learning 

personnel development standards funded under the State 

Advisory Council on Early Childhood Education and Care 

established under the Head Start Act, if applicable. (34 CFR 

§303.118)

12. The Statewide system includes policies and procedures relating to the 

establishment and maintenance of qualification standards to ensure that 

personnel necessary to carry out the purposes of Part C are 

appropriately and adequately prepared and trained. These policies and 

procedures provide for the establishment and maintenance of 
__________________

State

Part C Annual State Application: FFY 2015 Section II -19

OMB No. 1820-0550/Expiration Date: 

Check and enter date(s) as 

applicable

Subpart B – Assurances

(20 U.S.C. 1434; 1435; and 1437(b); 34 CFR §§303.101-126; 303.220; 303.227)

Yes

(Assurance is 

hereby 

provided.)

No

(Assurance 

cannot be 

ensured. 

Provide date 

on which 

State will 

complete 

changes in 

order to 

provide 

assurance.)

qualification standards that are consistent with any State-approved or 

State-recognized certification, licensing, registration, or other 

comparable requirements that apply to the profession, discipline, or area 

in which personnel are providing early intervention services. Nothing in 

Part C of the Act may 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 Part C of the 

Act to infants and toddlers with disabilities. (34 CFR §303.119(a) – (c))

13. The Statewide system includes a single line of responsibility in a lead 

agency designated or established by the Governor that is responsible for 

the following--

(a)(1) The general administration and supervision of programs and 

activities administered by agencies, institutions, organizations, and 

EIS providers receiving assistance under Part C of the Act; and 

(2) The monitoring of programs and activities used by the State 

to carry out Part C of the Act (whether or not the programs or 

activities are administered by agencies, institutions, 

organizations, and EIS providers that are receiving 

assistance under Part C of the Act), to ensure that the State 

complies with Part C of the Act, including--

(i) Monitoring agencies, institutions, organizations, and 

EIS providers used by the State to carry out Part C of 

the Act;

(ii) Enforcing any obligations imposed on those agencies,

institutions, organizations, and EIS providers under 

Part C of the Act and 34 CFR Part 303;

(iii) Providing technical assistance, if necessary, to those 

agencies, institutions, organizations and EIS providers; 

(iv) Correcting any noncompliance identified through 

monitoring as soon as possible and in no case later 

than one year after the lead agency’s identification of 

the noncompliance; and

(v) Conducting the activities in paragraphs (a)(2)(i) 

through (a)(2)(iv) of this section, consistent with 34 

CFR §§303.700 through 303.707, and any other 

activities required by the State under those sections.

(b) The identification and coordination of all available resources for 

early intervention services within the State, including those from 

Federal, State, local, and private sources, consistent with subpart F 
__________________

State

Part C Annual State Application: FFY 2015 Section II -20

OMB No. 1820-0550/Expiration Date: 

Check and enter date(s) as 

applicable

Subpart B – Assurances

(20 U.S.C. 1434; 1435; and 1437(b); 34 CFR §§303.101-126; 303.220; 303.227)

Yes

(Assurance is 

hereby 

provided.)

No

(Assurance 

cannot be 

ensured. 

Provide date 

on which 

State will 

complete 

changes in 

order to 

provide 

assurance.)

of 34 CFR Part 303. 

(c) The assignment of financial responsibility in accordance with 

subpart F of 34 CFR Part 303.

(d) The development of procedures in accordance with subpart F of 34 

CFR Part 303 to ensure that early intervention services are 

provided to infants and toddlers with disabilities and their families 

under Part C of the Act in a timely manner, pending the resolution 

of any disputes among public agencies or EIS providers.

(e) The resolution of intra- and interagency disputes in accordance 

with subpart F of 34 CFR Part 303. 

(f) The entry into formal interagency agreements or other written 

methods of establishing financial responsibility, consistent with 34 

CFR §303.511, 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 as set forth in subpart F of 34 CFR 

Part 303.

(34 CFR §303.120)

14. The Statewide system includes a policy pertaining to the contracting or 

making of other arrangements with public or private individuals or 

agency service providers to provide early intervention services in the 

State, consistent with the provisions of Part C of the Act and 34 CFR 

Part 303, including the contents of the application, and the conditions of 

the contract or other arrangements. The policy --

(a) Includes a requirement that all early intervention services must 

meet State standards and be consistent with the provisions of Part 

C; and 

(b) Is consistent with the Education Department General 

Administrative Regulations in 34 CFR Part 80. 

(34 CFR §303.121)

15. The Statewide system includes procedures for securing the timely 

reimbursement of funds used under Part C of the Act, in accordance with 

subpart F of 34 CFR Part 303. (34 CFR §303.122)

16. The Statewide system includes procedural safeguards that meet the 

requirements of subpart E of 34 CFR Part 303. (34 CFR §303.123)
__________________

State

Part C Annual State Application: FFY 2015 Section II -21

OMB No. 1820-0550/Expiration Date: 

Check and enter date(s) as 

applicable

Subpart B – Assurances

(20 U.S.C. 1434; 1435; and 1437(b); 34 CFR §§303.101-126; 303.220; 303.227)

Yes

(Assurance is 

hereby 

provided.)

No

(Assurance 

cannot be 

ensured. 

Provide date 

on which 

State will 

complete 

changes in 

order to 

provide 

assurance.)

17. The Statewide system includes a system for compiling and reporting 

timely and accurate data that meets the requirements of 34 CFR 

§§303.700 through 303.702 and 303.720 through 303.724 and the 

following requirements. The data system includes a description of the 

process that the State uses, or will use, to compile data on infants or 

toddlers with disabilities receiving early intervention services under Part 

C, including a description of the State’s sampling methods, if sampling is 

used, for reporting the data required by the Secretary under sections 616 

and 618 of the IDEA and 34 CFR §§303.700 through 303.707 and 

303.720 through 303.724. (34 CFR §303.124)

18. The Statewide system includes a State Interagency Coordinating Council 

(Council) that meets the requirements of subpart G of 34 CFR Part 303. 

 (34 CFR §303.125)

19. The Statewide system includes policies and procedures to ensure, 

consistent with 34 CFR §§303.13(a)(8) (early intervention services), 

303.26 (natural environments), and 303.344(d)(1)(ii) (content of an 

IFSP), that early intervention services for infants and toddlers with 

disabilities are provided--

(a) To the maximum extent appropriate, in natural environments; and 

(b) In settings other than the natural environment that are most 

appropriate, as determined by the parent and the IFSP Team, only 

when early intervention services cannot be achieved satisfactorily 

in a natural environment. 

(34 CFR §303.126)

20. The Statewide system ensures that Federal funds made available to the 

State under section 643 of the Act will be expended in accordance with 

the provisions of 34 CFR Part 303, including §§303.500 and 303.501. 

 (34 CFR §303.221)

21. The Statewide system will comply with the requirements in §§303.510 

and 303.511 in subpart F of this part. (34 CFR §303.222)

22. The Statewide system ensures that--

(a) The control of funds provided under 34 CFR Part 303, and title to 

property acquired with those funds, will be in a public agency for the 
__________________

State

Part C Annual State Application: FFY 2015 Section II -22

OMB No. 1820-0550/Expiration Date: 

Check and enter date(s) as 

applicable

Subpart B – Assurances

(20 U.S.C. 1434; 1435; and 1437(b); 34 CFR §§303.101-126; 303.220; 303.227)

Yes

(Assurance is 

hereby 

provided.)

No

(Assurance 

cannot be 

ensured. 

Provide date 

on which 

State will 

complete 

changes in 

order to 

provide 

assurance.)

uses and purposes provided in 34 CFR Part 303; and

(b) A public agency will administer the funds and property.

(34 CFR §303.223)

23. The Statewide system ensures that it will--

(a) Make reports in the form and containing the information that the 

Secretary may require; and

(b) Keep records and afford access to those records as the Secretary 

may find necessary to ensure compliance with the requirements of 

34 CFR Part 303, the correctness and verification of reports, and the 

proper disbursement of funds provided under 34 CFR Part 303.

(34 CFR §303.224)

24. The Statewide system ensures that –

(a) Federal funds made available under section 643 of the Act to the 

State –

(1) Will not be commingled with State funds; and 

(2) 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.

(b) To meet the requirement in paragraph (a) of this section, the total 

amount of State and local funds budgeted for expenditures in the current 

fiscal year for early intervention services for children eligible under this 

part and their families must be at least equal to the total amount of State 

and local funds actually expended for early intervention services for 

these children and their families in the most recent preceding fiscal year 

for which the information is available. Allowance may be made for—

(1) A decrease in the number of infants and toddlers who are eligible 

to receive early intervention services under this part; and 

(2) Unusually large amounts of funds expended for such long-term 

purposes as the acquisition of equipment and the construction of 

facilities.

(c) Requirement regarding indirect costs. (1) Except as provided in 

paragraph (c)(2) of this section, a lead agency under this part may not 

charge indirect costs to its Part C grant. 

(2) If approved by the lead agency’s cognizant Federal agency or by 

the Secretary, the lead agency must charge indirect costs through 

either--

(i) A restricted indirect cost rate that meets the requirements in 34 

CFR 76.560 through 76.569; or 
__________________

State

Part C Annual State Application: FFY 2015 Section II -23

OMB No. 1820-0550/Expiration Date: 

Check and enter date(s) as 

applicable

Subpart B – Assurances

(20 U.S.C. 1434; 1435; and 1437(b); 34 CFR §§303.101-126; 303.220; 303.227)

Yes

(Assurance is 

hereby 

provided.)

No

(Assurance 

cannot be 

ensured. 

Provide date 

on which 

State will 

complete 

changes in 

order to 

provide 

assurance.)

(ii) A cost allocation plan that meets the non-supplanting 

requirements in paragraph (b) of this section and 34 CFR Part 76 of 

EDGAR. 

(3) In charging indirect costs under paragraph (c)(2)(i) and (c)(2)(ii) 

of this section, the lead agency may not charge rent, occupancy, or 

space maintenance costs directly to the Part C grant, unless those 

costs are specifically approved in advance by the Secretary.

(34 CFR §303.225)

25. The Statewide system ensures that fiscal control and fund accounting 

procedures will be adopted as necessary to ensure proper disbursement 

of, and accounting for, Federal funds paid under 34 CFR Part 303.

(34 CFR §303.226)

26. The State ensures that policies and practices have been adopted to 

ensure that--

(a) Traditionally underserved groups, including minority, low-income, 

homeless, and rural families and children with disabilities who are 

wards of the State, are meaningfully involved in the planning and 

implementation of all the requirements of Part C; and

(b) These families have access to culturally competent services within 

their local geographical areas. 

(34 CFR §303.227)

Assurance Regarding Optional Policy

Enter 'NA’ in the cell to the left if this assurance is not applicable to your 

State.

27. A State may adopt and 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 paragraphs (a) and (b) of this section. (34 CFR 

§303.119(d))
__________________

State

Part C Annual State Application: FFY 2015 Section II -24

OMB No. 1820-0550/Expiration Date: 

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 arrangements to establish financial responsibility for the 

provision of Part C services among appropriate public agencies under §303.511 and 

the lead agency’s contracts with EIS providers regarding financial responsibility for the 

provision of Part C services meet the requirements in §§303.500 through 303.521 and 

are current as of the date of submission of the certification. (34 CFR §303.202)
__________________

State

Part C Annual State Application: FFY 2015 Section II -25

OMB No. 1820-0550/Expiration Date: 

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 20 U.S.C. 1431-1443 and the final regulations in 34 

CFR Part 303. 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 20 U.S.C. 1431-1443 and the final regulations 34 CFR Part 303, 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, 2016. (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 2015 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:
__________________

State

Part C Annual State Application: FFY 2015 Section III -1

OMB No. 1820-0550/Expiration Date: 

Section III

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

(Completion of this Section, III.A is optional for SEAs.)

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 

Funded

Number 

of 

Positions

% of 

Time 

Spent on 

Part C

Salaries 

& Fringe 

Benefits

Description of Duties

100% 

funded 

with Part 

C Funds

< 100% 

funded 

with Part 

C Funds

Subtotal 

of 

amount 

under A:
__________________

State

Part C Annual State Application: FFY 2015 Section III -2

OMB No. 1820-0550/Expiration Date: 

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.)

Major Activity Part C Funds 

to be Spent

Description of Activities

Subtotal of amount 

under B:
__________________

State

Part C Annual State Application: FFY 2015 Section III -3

OMB No. 1820-0550/Expiration Date: 

Section III (Continued)

C. Description of Use of Part C Funds for the Interagency Coordinating Council (ICC)2

 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 

Funded

Number 

of 

Positions

% of 

Time 

Spent on 

Part C

Amount 

of 

Salaries 

& Fringe 

Benefits

Description of Duties

100% 

funded 

with Part 

C Funds

< 100% 

funded 

with Part 

C Funds

Subtotal 

of 

amount 

under C:

 

2

Federal Part C funds used to support the SICC must meet the requirements of 34 CFR §303.603.
__________________

State

Part C Annual State Application: FFY 2015 Section III -4

OMB No. 1820-0550/Expiration Date: 

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 Activity Part C Funds 

to be Spent

Description of Activities

Subtotal of amount 

under D:
__________________

State

Part C Annual State Application: FFY 2015 Section III -5

OMB No. 1820-0550/Expiration Date: 

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 Part C, and the approximate amount for each direct service (States must 

disaggregate by service the approximate amount of funds expected to be expended for 

each direct service). 

Description of Each Direct Early Intervention Service Approximate Amount of Part C 

Funds to be Spent on Each Direct 

Service 

Subtotal of amount under E:
__________________

State

Part C Annual State Application: FFY 2015 Section III -6

OMB No. 1820-0550/Expiration Date: 

Section III (Continued)

F. Description of Optional Use of Part C Funds

If the State uses Part C funds for initiating, expanding, or improving collaborative efforts related to at-risk 

infants and toddlers, the application must include:

 The name of the major activity ;

 The approximate amount of funds to be spent; and

 A description of the activities.

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

Major Activity Part C Funds 

to be Spent

Description of Activities

Subtotal of amount 

under F:
__________________

State

Part C Annual State Application: FFY 2015 Section III -7

OMB No. 1820-0550/Expiration Date: 

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 Funds Amount of Funds Purpose

Subtotal of amount under 

G:
__________________

State

Part C Annual State Application: FFY 2015 Section III -8

OMB No. 1820-0550/Expiration Date: 

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. $

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) $ 
__________________

State

Part C Annual State Application: FFY 2015 Section IV -1

OMB No. 1820-0550/Expiration Date: 

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 34 CFR §§303.203(b)(1), 303.500(b), 303.520, and 

303.521 which may include use of public benefits or insurance, 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 

303.520(e) 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) and 34 CFR §303.225(a) and (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 3.a 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) 

Under 34 CFR §303.225(c), a lead agency may not charge indirect costs to its Part C grant unless the 

lead agency charges indirect costs through either-- (i) A restricted indirect cost rate that meets the 

requirements in 34 CFR §§76.560 through 76.569; or (ii) A cost allocation plan that meets the nonsupplanting requirements in paragraph (b) of this section and 34 CFR part 76 of EDGAR.

1. If the lead agency is not a State educational agency (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, 2016). (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 

____________________.

3

 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.

 

3

 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).
__________________

State

Part C Annual State Application: FFY 2015 Section IV -2

OMB No. 1820-0550/Expiration Date: 

_____ Other, explanation attached.

2. Check if applicable.

_____ Under 34 CFR §303.225(d), the lead agency may not charge rent, occupancy, or space 

maintenance costs directly to the Part C grant, unless those costs are specifically approved in 

advance by the Secretary. The lead agency is requesting the Secretary’s approval to charge 

rent, occupancy or space maintenance costs either directly or indirectly to Part C FFY 2014

funds. If checked, the lead agency must attach to this Application a description of the amount 

to be charged, all uses of the space, and the proposed method of charging.