Form Stac 202 – Fill Out and Use This PDF

INSTRUCTIONS FOR COMPLETING THE STAC-202 FORM

Designation of School District of Attendance for a Homeless Child

Education of homeless children means 1) a child or youth who lacks a fixed, regular, and adequate night-time residence, including a child or youth who is (i) sharing the housing of other persons due to a loss of housing, economic hardship or a similar reason; (ii) living in motels, hotels, trailer parks or camping grounds due to the lack of alternative adequate accommodations; (iii) abandoned in hospitals, (iv) awaiting foster care placement; or (v) a migratory child, as defined in § 1309(2) of the Elementary and Secondary Education Act of 1965, as amended, who qualifies as homeless under any of the provisions of clauses (i) through (iv) of this subparagraph or subparagraph two of this paragraph; or 2) a child or youth who has a primary nighttime location that is (i) a supervised publicly or privately operated shelter designed to provide temporary living accommodations including, but not limited to, shelters operated or approved by the state or local department of social services, and residential programs for runaway and homeless youth established pursuant to article nineteen-H of the executive law; or (ii) a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings, including a child or youth who is living in a car, park, public space, abandoned building, substandard housing, bus or train stations or similar setting.

1.Enter the youth’s complete last name and first name.

2.Enter the youth’s date of birth.

3.Place a check in the box which identifies the gender of the youth.

4.Enter the youth’s social security number, if known.

5.Place a check in the box which identifies, to the best of your knowledge, the racial/ethnic category with which the youth most closely identifies.

Racial/Ethnic Categories:

American Indian or Alaskan Native - A person having origins	Black – A person having origins in any of the black racial
in any of the original peoples of North America, and who	groups of Africa.
maintains cultural identification through tribal affiliation or
community recognition.	Hispanic – A person of Mexican, Puerto Rican, Cuban, Central
	or South American, or other Spanish culture or origin, regardless
Asian or Pacific Islander – A person having origins in any of	of race.
the original peoples of the Far East, Southeast Asia, the Indian
Subcontinent, or the Pacific Islands. This area includes, for	White – A person having origins in any of the original peoples
example, China, India, Japan, Korea, the Philippine Islands, and	of Europe, North Africa, or the Middle East.
Samoa.

6.Enter the grade level for which placement is being sought.

7.Enter the complete last permanent address prior to becoming homeless.

7A. Enter the name of the school district that served the area where the child resided prior to becoming homeless.

7B. Enter the name of the school district where the student was last enrolled. This will be different from 7A if the student was previously temporarily housed in a different district and enrolled in that district as a non-resident homeless student.

8.Enter the complete address of current temporary housing including the name of the shelter if applicable and the date the student moved to the current location. If the location is confidential (for example, if the student is living in a domestic violence shelter), the name and address of the location do not need to be provided.

8A. Enter the name of the school district of current location.

9.Enter the date of designation.

9A. Enter the name of the designated school district of attendance. One of four districts may be designated to provide the educational component: District of attendance before becoming homeless,

District where last enrolled,

District of current location of temporary housing, or District participating in a Regional Placement Plan (RPP).

10.Enter, if applicable, the date the child moved to permanent housing and is no longer eligible as a homeless student.

11.If the student attends school in a district participating in a Regional Placement Plan or the district where last enrolled (7B), and that district is different from both the district of attendance before becoming homeless (7A) and the district of current location (8A), check the corresponding box where the student attends school (either the District participating in a Regional Placement Plan or the District where last enrolled).

12.Print the name and telephone number of the designator. The designator can be the parent, person in parental relation, the unaccompanied youth (a youth who meets the definition of homeless and is not in the physical custody of a parent or guardian), or the director of a residential program for runaway and homeless youth if the student is living in such a program.

13.The signature of the designator and current date.

14.Print the name of the local Department of Social Services or School District representative and title.

15.The signature of the local Department of Social Services or School District representative is required attesting that this child has moved to temporary housing. A telephone number is required in case the STAC & Special Aids Unit has questions relating to the information provided.

16.The name of the local Department of Social Services that has placed the child in temporary housing, if applicable.

NOTE: Copies should be distributed to the following:

1.State Education Department, only if designated district of attendance is entitled to reimbursement for educational services pursuant to N.Y. Educ. Law § 3209(3);

2.Designated School District of Attendance;

3.District of Attendance before becoming homeless;

4.District where last enrolled;

5.Parent/Guardian/Unaccompanied youth/director of a residential program for runaway and homeless youth; and

6.Local Department of Social Services, only if placed in temporary housing by DSS.