SED CODE
Form SA-16
The State Education Department
Octo007
February 2011
SUBMIT ORIGINAL AND
State Aid Office, Room 507 West, Education Building
ONE COPY TO:
Albany, New York 12234
Clear Entire Form
(518) 474-2977
Fax: (518) 473- 9808
Clear Bus Data Only
APPLICATION FOR APPROVAL OF BUS PURCHASE FOR PURPOSES OF STATE AID
Print Form
Contact Person:
__________________________________
Tel: (
)
_______________
Ext:
______
Fax (
)
___________________
School District/
:
_____________________________________________________________________
BOCES
_____________________________________________________________________
Mailing Address:
Street
_____________________________________________________________________
Bus No.
City
State
Zip Code
Vin Number
Was Bus purchased under State contract award? Submit a copy of the purchase order with itemized options and the cost of each option
NO
YES
YEAR
_______
AWARD NO
__________
PAGE NO
________
Vendor Discount Applied To Options
_______
%
Was Bus Locally Bid?
NO
YES
For locally bid buses, you must submit a copy of the purchase order and a copy of the
successful bid proposal with itemized options and the cost of each option
Pupil Capacity*
Chassis Type
Number of Wheel Chair Lifts
Number of Wheel Chair Stations
Conventional Bus is <28 capacity
Was Bus Converted for Wheelchairs? (ALL conversions
*See #7 on reverse
Bus (Capacity = or >28)
including fuel and/or wheelchairs of either new or previously
Model Year
Cutaway
purchased vehicles requires submission of a new SA-16 and
Van
Department of Transportation approval)
Engine Classification
If capacity = or > 28
Carryall
NO
YES
Passenger Car
Conventional
Passenger Van
Type
of Fuel Used by t
he
New Bus
Diesel
Gas
Forward Control
Propane
CNG
Other (Specify)
Sport Utility Vehicle
Rear Engine
Other (Specify)
If the capacity of the vehicle is less than 10, is the vehicle assigned to a regular route and used 100% of the time to transport students to and
from school?
Yes
No
Gross Cost of Bus (Including Options)
.
Less any Trade-In Allowances or Volume Discount
Less any Federal or State Grants.
Equals the net purchase price of the new bus.
$0.00
Insurance Recovery ST-3 - A2680 and H2680. (This deduction is done automatically in the school year in which
the amount is
reported on the ST-3)
Full payment amount (if more or less than the net purchase price please attach an explanation).
Date that the bus described above was delivered to the district.
Purchase Order date.
Financed purchase
Cash purchase
Borrowing date. (If the purchase of this bus is financed indicate the borrowing date to the left)
Date that payment was made. Applications subm
itted later than one year after pa
yment to the vendor require
a late filed excuse letter from the superintendent.
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