Form Preschool Stac-1 - Request For Commissioner'S Approval Of Reimbursement For Services For Students With Disabilities - The University Of The State Of New York, The State Education Department Page 2

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Racial/Ethnic Groups
All students must be reported as Hispanic/Latino or not Hispanic/Latino. In addition, all students must be reported with at
least one race. Students who are reported as Hispanic/Latino, regardless of their race, will be counted as Hispanic or Latino
for accountability and other reporting purposes. Students who are reported as not Hispanic/Latino will be counted in the race
category in which they are reported for accountability. Non-Hispanic students who are reported with more than one race
category will be reported as Multiracial for accountability.
Complete Signature Section
MUNICIPALITY OR CITY OF NEW YORK SIGNATURE SECTION
A. SERVICES PROVIDED PRESCHOOL CHILDREN IN AN APPROVED SED PROGRAM UNDER
SECTION 4410 OF THE EDUCATION LAW.
The MUNICIPALITY of __________________________________________________ has received on
______________________, 20____ the STAC-1 Authorization of Placement regarding the above-named
preschool child requiring educational services as authorized by the Board of Education and served by an
agency approved to provide such special educational services by the Commissioner of Education and with
whom this municipality has entered into a contract in accordance with the Regulations of the
Commissioner of Education and Section 4410 of the Education Laws. Any transportation services
provided must be in accordance with Section 4410 and Section 103 of the General Municipal Law.
Signature:____________________________________________________________
Date: ___________________________________
B. RELATED SERVICES PROVIDED PRESCHOOL CHILDREN IN ACCORDANCE WITH SECTION 4410
OF THE EDUCATION LAW.
The MUNICIPALITY of ______________________________________________________ has received
on______________________, 20____ the STAC-1 Authorization regarding the above-named preschool
child requiring Related Services as authorized by the Board of Education for an educational rate set by the
Municipality in accordance with Section 4410 of the Education Law. Any transportation services
provided must be in accordance with Section 4410 and Section 103 of the General Municipal Law.
Signature:____________________________________________________________
Date: ___________________________________
PERSON COMPLETING THIS FORM
Name
Telephone
(Area Code)
(Number)
(
)
Title
Email
RETURN TO:
NEW YORK STATE EDUCATION DEPARTMENT
STAC & SPECIAL AIDS UNIT
EDUCATION BUILDING ROOM 514W
89 WASHINGTON AVENUE
ALBANY, NEW YORK 12234
(518) 474-7116

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