STATE BOARD OF EDUCATION
STATE DEPARTMENT OF EDUCATION
ADMINISTRATIVE CODE

APPENDIX
FORMS

290­080­092­.03(1)  CFSE FORM 1 Application Form
290­080­092­.03(2)  CFSE FORM 2 Reimbursement Form

CFSE Form 1





See Master Code for copy of form

STUDENT INFORMATION

Name of Student:_________________________________________________
First Name, Middle, Last(Family Name), Suffix

Student's Social Security Number:________________________________

Age/Birthdate:             /_____________________________________
Day       Month       Year

Sex:__________________________Race:______________________________

Name of School:__________________________________________________

Location of School:______________________________________________

Mailing Address:_________________________________________________

_________________________________________________________________
City                  State            Zip        Plus 4

In the space below, provide a detailed statement of the facts and circumstances surrounding the catastrophic services needed because of the student's disability:

STATEMENT OF FINANCIAL NEED

In the spaces below, provide detailed statements of the type service(s) needed and the cost of each service due to facts and circumstances surrounding this request for financial assistance:

1. 1. Statement of services needed and the expected cost of each service for the fiscal year ending September 30.
2. 2. Statement of the financial impact on the special education program of the local education agency if such services were funded solely by the local education agency.
3. 3. Statement of the financial impact on the entire local education agency if this grant is not approved.

4. 4. Statement showing each anticipated source of funds (including local) for the proposed expenditures in this application by the local education agency special education program.  This shall include the amount needed to provide the required local match for catastrophic funds.

   ALABAMA CATASTROPHIC TRUST FUND
   FOR SPECIAL EDUCATION APPLICATION PROCESS

                           GRANT APPLICATION
   Pursuant to Alabama Administrative Code Chapter 290­-080-­092.

   Any county of city school system in the State of Alabama that has enrolled an exceptional child with disabilities determined eligible for Special Education and related services under existing federal and state law, may make a grant application to the State Superintendent of Education for financial assistance when the special education and related services for that particular child are unduly expensive, extraordinary and/or beyond the routine and reasonable education and services provided.

   Questions regarding these rules and the application process should be directed to:

   DR. BILL EAST
   DIVISION OF SPECIAL EDUCATION SERVICES
   GORDON PERSONS BUILDING, ROOM 3346
   50 NORTH RIPLEY STREET
   MONTGOMERY, AL 36130-­3901
   TELEPHONE: (205)242­-8114 OR 1­-800-­392-­8020

   SUBMISSION OF APPLICATION:

   An original and three (3) copies must be forwarded to:

   DR. WAYNE TEAGUE
   STATE SUPERINTENDENT OF EDUCATION
   ROOM 5115, GORDON PERSONS BUILDING
   50 NORTH RIPLEY STREET
   MONTGOMERY, AL 36130­-3901

   CFSE Form 2

   See Master Code for copy of form