Request for STAC Forms

The following STAC forms are available in PDF format. Click on the form link below.

  • Preschool STAC-1 pdf - Preschool Request for Commissioner's Approval of Services for students with Disabilities
  • Preschool Student-Specific Nurses and Interpreters pdf -
    Preschool Request for Reimbursement for All Student-Specific Nurses and All Student-Specific Interpreters
  • School Age STAC-1 pdf - School Age Request for Commissioner's Approval of Services for students with Disabilities
  • School Age Student-Specific Aides, Nurses, and Interpreters pdf -
    School Age Request for Reimbursement for All Out-of-State Student-Specific Education Aides,
    All Student-Specific Nurses, All Student-Specific Interpreters, and All Student-Specific Maintenance Aides
    (See list of excluded school age providers)
    NOTE: Maintenance aides may be requested for CSE-placed students in either an eligible in-state or out-of-state residential facility, excluding Children's Residential Project (CRP) Programs.
  • Aide Percentage Calculation Worksheet pdf
  • OPWDD STAC-200 pdf - Notice of Other State Agency (OPWDD) Placement of Children with Handicapping Conditions.
  • OMH STAC-200 pdf - Notice of Other State Agency Placement of Children with Handicapping Conditions
  • OCFS LDSS 3424 - School District Notification Of Financial Responsibility for Educationally Handicapped Foster Child Placed in a Child Care Institution
  • STAC-202 pdf - (DSS) Designation of School District of Attendance for Children in Temporary Housing
  • STAC-5 pdf - Request for Commissioner's Approval of Reimbursement for Evaluations.
    Please note: This form has been optimized as a fillable form with additional accessibility support for visitors with visual impairments. It is a large file and may take a little while to download. After the form finishes downloading, we recommend saving a local copy to your computer for future use.
  • Summer Transportation Cost Exceeding $6,500 pdf - Summer Transportation Costs Exceeding $6,500+
  • Summer Related Services Exceeding 120 Half-Hour Units pdf - 4408 Summer 9015 Programs
  • Nonresident Parentally-placed Nonpublic School Students:
  • Public High Cost Calculation Worksheets:
    Use these PDF calculation versions of the Public High Cost Worksheets to document updated costs for claims that were previously verified and locked. These versions of the forms can also be used to calculate estimated costs prior to entry on the STAC Online (EFRT) System.
    • DCPUB PDF Document - High Cost Worksheet for In-District/BOCES Placements
    • DCPOD pdf - High Cost Worksheet for "Other District" Placements
    Please note:
    Enter the value from Line 4 of the PUB State Aid Output Report in the Public Excess Cost Aid Ratio box.
    Enter the value from Line 5 of the PUB State Aid Output Report in the District Threshold box.
    The correct State Aid Output Report will be one year more recent than the enrollment year.
  • STAC Online System (EFRT) Forms:

    The STAC-200s are five-part forms. To request hard copies of these forms please contact the STAC and Medicaid Unit by phone (518) 474-7116, fax (518) 402-5047 or email OMSSTAC@nysed.gov.

Last Updated: January 4, 2021