DPI-0013 Title I, Part a Carryover Waiver

Wisconsin Department of Public Instruction INSTRUCTIONS: Complete form and submit it to DPI. Send TITLE I, PART A CARRYOVER WAIVER completed form to: DPI-0013 (Rev. 10-17) WISCONSIN DEPARTMENT OF PUBLIC INSTRUCTION TITLE I AND SCHOOL SUPPORT TEAM ATTN: ESEA OOA PO BOX 7841 Grant Year: 2016-17 MADISON, WI 53707-7841

FUNDS UNDER TITLE I, PART A OF THE ELEMENTARY AND SECONDARY EDUCATION ACT OF 1965 This waiver allows an LEA to carryover more than 15 percent of its 2016-17 Title I, Part A allocation. I. ASSURANCES

1. The LEA determined a reasonable and necessary need to spend the funds over two years. 2. The LEA thoughtfully considered how it will spend its Title I, Part A funds over two years.

II. GENERAL INFORMATION School District Mailing Address Street, City, State, ZIP

District Administrator E-Mail Address Phone Area/No.

District Title I Coordinator E-Mail Address Phone Area/No.

III. NARRATIVE Why did the district expend less than 85 percent of the Title I, Part A allocation? Limit narrative to space provided.

IV. CERTIFICATION/SIGNATURE

I CERTIFY that the assurances listed above have been satisfied and that all facts, figures, and representation in this application are correct to the best of my knowledge. Signature of District Administrator Date Signed Mo./Day/Yr. 

FOR DPI USE Reason for Denial Approved Denied

Did the district receive a waiver of the carryover limitation with respect to its: 2015-16 Allocation? 2014-15 Allocation?

Yes No Yes No Signature of Waiver Approver Date Signed Mo./Day/Yr. 