august 2015 =========== new york state nonpublic school application =========================================== reimbursement for

August 2015
===========
New York State Nonpublic School Application
===========================================
Reimbursement for School Safety Equipment
=========================================
Years 2 and 3
=============



BEDS Code: OSC Vendor ID:
School Name:
School Address:
Year 1 Carryover
+
Year 2 Allocation
+
Year 3 Allocation
=
Total Allocation
+
=
Unreimbursed Approved Expenditures Year 1
Choose an Option:
Use Total Allocation to pay unreimbursed eligible expenditures
from Year 1
*
No further documentation is required
Use Total Allocation to reimburse for expenditures not
included in Year 1 claim
*
Complete Summary of Expenditures section
*
Submit invoice and proof of payment
Use Total Allocation to reimburse for a combination of the
above two options
*
Complete Summary of Expenditures section for expenditures not
included in Year 1 claim
*
Submit invoice and proof of payment for expenditures not included
in Year 1 claim
School Safety Certification
I hereby certify that the expenditures reported have been incurred and
calculated in accordance with all applicable statutes, regulations and
guidelines; that the school at which the services were performed is
not a for-profit entity; the claim is just and correct; and that the
balance is due and owing. Any required building permits were obtained
prior to the work being completed. Itemized receipts and proof of
payment for the purchase and installation of approved items are
available upon request.
Original Signature of Chief Administrator
Chief Administrator Name
(PLEASE PRINT)
Date
Chief Administrator Email Address
Telephone Number
Fax Number
Person Completing Form
(PLEASE PRINT)
Title of Person Completing Form
Telephone Number
Completed forms should be mailed to: NYS Education Department, Office
of Grants Management Room 481, EBA Albany, NY 12234
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Summary of Expenditures
Scope of Work
(Check the scope of work that applies below, then fill in costs for
purchase and installation in the appropriate columns to the right)
Equipment Purchase
Installation
Cost
External lighting to illuminate primary entrances
Internal security cameras
Access control systems: Check all those that apply and
indicate the cost for each in the appropriate column.
These may include:
Do not include cost here
Do not include cost here
An intercom to speak with visitors;
Remote electronic door unlatching systems;
External cameras;
Interface with the building management system;
I nternal security cameras.
Central lockdown buttons, etc.;
Screens and other devices for monitoring cameras remotely.
Other: Please specify
Door replacement
Door hardware replacement
Door frame replacement
Sidelight removal;
Sidelight frame replacement; opening size
Change door or sidelight glass materials;
Bars, Grills or other protective measures over existing glass
to prevent access;
Glass films including security films or tinted films; or
Other: Please specify
Subtotal by Category
Combined Total
Total Allocation
2

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