Request for STAC Forms
The following STAC forms are available in PDF format. Click on the form link below.
- Preschool STAC-1 - Preschool Request for Commissioner's Approval of Services for students with Disabilities
- Preschool 1:1 Aide
Preschool Request for Reimbursement for Partial
1:1 Aide, 1:1 Nurse, 1:1 Interpreter
(See list of excluded preschool providers)
- School Age STAC-1 - School Age Request for Commissioner's Approval of Services for students with Disabilities
- School Age 1:1 Aide - School Age Request for Reimbursement for Part-Time/Shared 1:1 Aides and 1:1 RN, 1:1 LPN, 1:1 Interpreters f/t Deaf
- OPWDD STAC-200 - Notice of Other State Agency (OPWDD) Placement of Children with Handicapping Conditions.
- OMH STAC-200 - 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 - (DSS) Designation of School District of Attendance for Children in Temporary Housing
- STAC-5 - Request for Commissioner's Approval of Reimbursement for Evaluations.
- Rates Exceeding $105,000/$95,000 - High Cost Student Data Report for Students with 10-month Education Rates of $104,999 (2013-14) or $94,999 (2012-13)
- DVPUB Signature Form (2014-15) - Form for Online Verification of High Cost Public Placements (In-District, Other District, and BOCES)
- Summer Transportation Cost Exceeding $6,500/$6,000 - Summer Transportation Costs Exceeding $6,500/$6,000+
- Summer Related Services Exceeding 120 Half-Hour Units - 4408 Summer 9015 Programs
- Nonresident Parentally-placed Nonpublic School Students - District Application for Administrative Review of a Claim for Payment
- STAC Online System (EFRT) Forms:
- Request for Addition to Drop Down Menu Form 329 kb (fax completed forms to 518-402-5047)
- Request to Change Program Dates Form 345 kb (fax completed forms to 518-402-5047)
- Request Access to the STAC Online System:
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 email@example.com.