LOCAL EDUCATIONAL AGENCY REPORT

Annual Survey of Children in Local Institutions
for Neglected or Delinquent Children
For School Year 2010-11 Title I Funding Purposes


This report is required by Sections 1124 and 1421 of Title I ESEA. Failure to submit this report will result in the loss of funds to the local educational agency to provide services to meet the needs of the children residing in this institution.
SECTION I - INSTITUTION AND SCHOOL DISTRICT

Legal Name of Institution:
Address of Institution:
Type of institution (Select only one to identify the type of institution being reported).
"Institution for neglected children" is a public or private residential facility, other than a foster home, that is operated for the care of children and youth who have been committed to the institution or voluntarily placed in the institution under applicable State law due to abandonment, neglect or death of their parents or guardians.
"Institution for delinquent children" is a public or private residential facility, other than a foster home, that is operated for the care of children and youth who have been adjudicated delinquent or in need of supervision.
3.A. Name of LEA in which children residing in this institution attend school
3.B. Address (Number, Street, City, State and Zip Code)
4. Caseload:
Total number of children aged 5-17 who lived in the institution for at least one day during a 30 consecutive day period, at least one day of which falls within the month of October 2009.


SECTION II - BASIS FOR ELIGIBILITY
1. Is this institution operated primarily for the care of:
A. Children who are orphaned or have been abandoned or neglected by parents or persons acting in place of parents?
Yes No
B. Children who have been determined by appropriate state or local authority to be delinquent or in need or supervision?
 Yes No
2. Is this institution a residential facility in which children are under 24-hour care? Yes No
3. Do the caseload data reported in item 4 above include only children aged 5-17 inclusive? Yes No


I CERTIFY that the information provided on this form is, to the best of my knowledge, complete and accurate. Submission serves as signature of assurance. A knowingly false claim on this report is a criminal offense under U.S. Code, Title 18, Section 1001 or Section 287.