Request for STAC Forms

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

Forms Requiring Personally Identifiable Student Information

Upload completed forms to SED File Transfer Manager (FTM) “inbasket”. After uploading, send a notification email to OMSSTAC@nysed.gov with your agency's SED Code and the complete filename.

STAC-1 Forms:

  • Preschool STAC-1 pdf - Preschool Request for Commissioner's Approval of Services for students with Disabilities
  • School Age STAC-1 pdf - School Age Request for Commissioner's Approval of Services for students with Disabilities

STAC-5 Forms:

  • 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.

Aide/Nurse/Interpreter Forms:

Eligibility Forms:

  • 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

School Age Summer Forms:

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.

Update Child Information:

Forms Not Requiring Personally Identifiable Student Information

Scan and email completed forms to OMSSTAC@nysed.gov.

STAC Online System (EFRT) Forms:

Last Updated: April 20, 2022