Title I, Part a Title I, Part a Carryover

Office of Field Services Request to Relinquish Federal Funds Form

The Local Educational Agency (LEA) / Public School Academy (PSA) / Intermediate School District (ISD) not applying for any or all Federal funds for the current Fiscal Year (FY) must complete this Request to Relinquish Federal Funds Form. This Form must be e-mailed to [email protected] by November 30 of the current FY in order to relinquish funds for that FY; and must be re-submitted each FY the funds are to be relinquished. This Form must be signed by both the Superintendent / Director and the President of the School Board, and must be accompanied by a Board Resolution or Approved Board Action to relinquish funds.

LEA/PSA/ISD Name wishes to relinquish the following Federal funds for the Current Fiscal Year FY:

Title I, Part A Title I, Part A Carryover

Title I, Part C - Regular School Year Migrant Title I, Part C - Summer Migrant Title I, Part D Title I, Part D Carryover

Title II, Part A Title II, Part A Carryover

Title III, Part A - Immigrant Students Title III, Part A - Immigrant Students Carryover Title III, Part A - English Learners Title III, Part A - English Learners Carryover Title IV, Part A Title IV, Part A Carryover

Title V, Part B - Rural and Low-Income Schools Title V, Part B - Rural and Low-Income Schools Carryover Title IX - Homeless Students Title IX - Homeless Students Carryover

One of the following is attached:

Board Resolution Approved Board Action

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______Superintendent/Director Signature President of the School Board Signature