To: - New York State Education Department
THE STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234
Office of Information and Reporting Services
Room 863 EBA
Albany, NY 12234
To: Non-Public School Administrator
Please complete the information below and fax this form to Cheryl Mitchell’s attention at (518) 474-4351. Thank you.
The individual named below is authorized to certify Mandated Services Aid AND Comprehensive Attendance Policy (CAP) forms in accordance with the school’s policies for this purpose. This person will receive all communications about Mandated Services Aid and CAP and will be the contact person regarding any claim issues.
BEDS Code
School Name: ________________________________________________
Last Name:___________________________First Name:________________ MI: ____
E-Mail Address: ____________________________________________
Telephone Number:______________________Fax Number: __________________
Chief Executive Officer Signature: _________________________________________
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