Spreadsheet: 079ae3c6-0fa2-4a41-a9ed-9006410c90e2
Sheet: Tuition Billing Appeal

 |  | Division of School Finance Special Education Funding and Data 1500 Highway 36 WestRoseville, MN  55113-4266 | n/a | TUITION BILLING APPEAL FORM FOR CARE AND TREATMENT |  |  |  |  |  |  |  | ED-02475-01
GENERAL INFORMATION AND INSTRUCTIONS: This form is to be used when requesting an appeal for care and treatment if the Tuition Billing System is not covering
the cost for providing special education services to nonresident students. Activity reports to support the expenditure data for the site must be attached. Put the ORG
code of the site for all receipts for that site from other billing, e.g. regular education, out-of-state and wards of the state, etc. For more information on special
instructions for nonresident children, see Minnesota Statutes, section 125A.11 at https://www.revisor.mn.gov/statutes/?id=125A.11. |  |  |  |  |  |  |  |  |  | n/a | n/a | n/a
DISTRICT
District Name: |  | n/a | n/a | n/a | n/a | n/a | District Number: |  | n/a | District Type: |  | n/a
SITE NAME AND NUMBER
Site Name: |  | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | Site Number:
Year Appealing: |  | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a
 |  | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a
LINE ITEM | [NAME] |  |  |  |  |  |  |  |  | COST/CALCULATIONS
1 | Total Out-of-State Tuition (Students with and without IEPS) |  |  | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a
2 | Total Non-IEP Invoices - Revenue |  | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a
3 | MDE Tution Revenue (include date) |  | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a
4 | Wards of the State (Anticipated) |  | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a
5 | Special Education Aid |  | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a
6 | Compensatory Revenue (FIN 317) |  | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a
7 | Other Revenue (specify) example: Q-Comp FIN 335 |  | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a
8 | TOTAL REVENUE (sum lines 1 through 7) |  | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a
9 | Total Expenditures (including benefits, excluding [NAME] and federal funds, (Total by Site from UFARS) |  |  |  |  |  |  | n/a | n/a | n/a | n/a
10 | UNREIMBURSED COSTS (line 9 - 8) |  | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a
11 | Number of Hours in a School Day (MARSS A File) |  | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a
12 | Number of Instructional Days in a Year (MARSS A File) |  | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a
13 | NUMBER OF MEMBERSHIP HOURS PER ADM (line 11 x line 12) |  |  | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a
14 | Number of Special Education ADM |  | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a
15 | TOTAL SPECIAL EDUCATION MEMBERSHIP HOURS (line 13 x 14) |  |  | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a
16 | UNREIMBURSED COSTS PER MEMBERSHIP HOURS (line 10 / 15) |  |  | n/a | n/a | n/a | n/a | n/a | n/a | n/a | n/a
VERIFICATION OF INFORMATION
n/a | I hereby verify tha the inforMation provided on this form is true and accurate to the best of my knowledge: |  |  |  |  |  |  | n/a | n/a | n/a | n/a | n/a
n/a |  |  |  |  |  |  |  | n/a | n/a | n/a | n/a | n/a
n/a |  |  |  |  |  |  |  | n/a |  |  |  | n/a
n/a | Signature - Director of Special Education |  | n/a | n/a | n/a | n/a | n/a | n/a | Date | n/a | n/a | n/a
End of form