U.S. Department of EducationImpact Aid ProgramWashington, D.C. 20202-6244PAGE: 1Final Filing Date:GRADE SPAN MAINTAINED LEGAL CLASSIFICATION (If different from grade span)01/31/2013Submit an original and 1 copy to the Impact Aid Program.APPLICATION FOR IMPACT AID - SECTION 80032014Send 1 copy to the State Educational Agency(SEA) using the attached transmittal form.Applicants must submit completeapplications (ED Form 4019) on or beforethis filing deadline to receive fullpayments. See the instructions forfurther information.APPLICANT NAME :STREET/P.O. BOX :CITY :COUNTY :STATE & ZIP :MEMBERSHIP SURVEY DATEFirst (Required) :Second (Optional) :IMPACT AID # :DUNS # :SURVEY FORMS :ORIGINAL APPLICATION :AMENDMENT :SOURCE CHECK :PR/AWARD # :CHECK TO APPLY FOR FUNDING UNDER SECTION 8003(b)(2) FOR HEAVILY IMPACTED LEAs. (If you check this box, the Impact Aid Program will contactyou to request additional information.)NAME AND TITLE OF AUTHORIZED REPRESENTATIVE (Please type or print.)SIGNATURE DATEI certify that I have read the statementscontained in this application and that these statements and all of the data includedin this application are, to the best of my knowledge andbelief, true, complete, and correct. I certify that I am authorized to make the representations and commitments in this application, for and on behalf of the applicant and otherwise toact as the applicant's authorized representative in submittingthis application for funding under section 8003 of the Impact Aid Program (Title VIII of the Elementary and SecondaryEducation Act). I declare that the applicantwill mail a complete copy of this application to the SEA at the same time that itmails this application to the U.S. Department of Education.CONTACT PERSON NAME :TITLE :PHONE :FAX :E-MAIL :PAGE: 2The applicant local educational agency (LEA) hereby declares that it has filed the following assurances and certifications covering the Impact Aid Program (Title VIII of the Elementaryand Secondary Education Act (ESEA)) with the U.S. Department of Education, and, as ofthe date of the signature below, reaffirms and incorporates by reference those assurances andcertifications in this Impact Aid application.* The LEA certifies that no circumstances affecting the validity of the following assurances have changed since their previous filing:••••••••*If the applicant is applying for Impact Aid assistance for the first time, the applicant also must file with the Impact Aid Program by the deadline for filing this application the followingassurances and certification that it can obtain from the IAP: OMB Standard Form 424B (Assurances for Non-Construction Programs) and ED Form 80-0013 (certification regardinglobbying).DATE:SIGNATURE:IMPACT AID PROGRAM ASSURANCES AND CERTIFICATIONSIt is hereby advised that, under section 8011 of the Impact Aid law, it is entitled to request an administrative hearing on, and/or review or reconsideration of, any action of theDepartment under the Impact Aid law that adversely affects or aggrieves the applicant; any such requests are governed by the regulations in 34 CFR Part 222, Subpart J,except for requests for hearings concerning Indian policies and procedures, tribal complaints, and withholdings that are governed by the regulations at 34 CFR Part 222,Subpart G. Any request for a hearing, review or reconsideration under 34 CFR Part 222, Subpart J, must be made in writing andsubmitted within 60 calendar days from thedate of the applicant's notice (receipt) of the adverse action to: Director, Impact Aid Program, United States Department of Education, 400 Maryland Ave., SW, Washington,D.C. 20202-6244.For any children claimed who reside on eligible Indian lands, policies and procedures have been established as required by section 8004 of the Impact Aid law, and havebeen adequately disseminated to the tribes and parents of children residing on eligible Indian lands. A copy of the current policies and procedures or a waiver statementfrom the local Indian tribe(s) is attached (see instructions for further information); andIt will use fiscal control and fund accounting procedures that will ensure proper disbursement of, and accounting for any Impact Aid payments received for federallyconnected children with disabilities claimed on Tables 1 and 2, and will use those funds to provide a free appropriate public education to those children in accordance withthe Individuals with Disabilities Education Act (IDEA) (20 U.S.C., 1400 et seq.). The special education programs provided to the children with disabilities claimed in thisapplication conform to the policies, procedures and requirements of the (IDEA);It will comply with all applicable statutes, regulations, and requirements concerning this grant, including requirements of theImpact Aid law (Title VIII of the ESEA), theprogram regulations (34 CFR Part 222), and program administrative requirements;It is a local educational agency that was created and authorized to operate schools, has administrative control and direction of free public education in the school districts,and that it may legally accept and disburse Federal funds to aid in financing its expenditures;The LEA further assures that:With respect to the Certification Regarding Lobbying, the LEA recertifies that no Federal appropriated funds have been paid orwill be paid to any person for influencing orattempting to influence an officer or employee of Congress, or an employee of a Member of Congress in connection with the making or renewal of Federal grants under thisprogram; that the LEA will complete and submit Standard Form LLL, "Disclosure Form to Report Lobbying," when required (34 CFR Part 82, Appendix B); and that the LEAwill require the full certification, as set forth in 34 CFR Part 82, Appendix A, in the award documents for all subawards at all tiers.The certification regarding lobbying in ED Form 80-0013; andAs applicable, the assurances in OMB Standard Form 424B (Assurances for Non-Construction Programs), relating to legal authorityto apply for assistance; access torecords; conflict of interest; merit systems; nondiscrimination; Hatch Act provisions;labor standards; flood insurance; environmental standards; wild and scenic riversystems; historic preservation; protection ofhuman subjects; animal welfare; lead-based paint; Single Audit Act; and general agreement to comply with all Federal laws,executive orders and regulations;APPLICATION FOR IMPACT AID - SECTION 8003PAGE: 3-1(2) (3)CHILDREN WITH DISABILITIES NUMBER OF CHILDREN ON SURVEY DATE(1)PROPERTY CODE NUMBERNUMBER OFCHILDREN ONSURVEY DATE(6)(5)TABLE 1-2. CHILDREN WITH DISABILITIESCHILDREN WITH DISABILITIESPROPERTY CODENUMBER(4)TABLE 1-1 TOTAL = >0000-0010*0000-0015*1435-0010*WITH A PARENT ON ACTIVE DUTY IN THEUNIFORMED SERVICES OF THE UNITED STATESWITH A PARENT WHO IS BOTH AN ACCREDITEDFOREIGN GOVERNMENT OFFICIAL AND A FOREIGNMILITARY OFFICERRESIDING ON ELIGIBLE INDIAN LANDSproperty (i.e., the official name, street address, city, and state).Properties listed on this page were claimed in the LEA's prior year application.An LEA may add any property it believes is eligible, without a property code number.However, it must indicate the specificlocation of each parcel of claimedNOTE: TABLE 1-1 TOTAL AND TABLE 1-2TOTAL MUST BE THE SAME.TABLE 1-2 IS A SUMMARY OF ALLCHILDREN ON TABLE 1-1.TABLE 1-2 TOTAL = >CHILDREN WITH DISABILITIES WHOOF THE UNITED STATES; OR (2) HAVE A PARENT WHO IS BOTH ANACCREDITED FOREIGN GOVERNMENT OFFICIAL AND A FOREIGN MILITARY OFFICER(Include only children enrolled in state-approved special education programs on this table. Exclude these children from Tables 1, 3, 4, and 5.)TABLE 2:0000-0010*0000-0015*WITH A PARENT ON ACTIVE DUTY IN THEUNIFORMED SERVICES OF THE UNITED STATESWITH A PARENT WHO IS BOTH AN ACCREDITED FOREIGNGOVERNMENT OFFICIAL AND A FOREIGN MILITARY OFFICERTABLE 2 TOTAL = >APPLICATION FOR IMPACT AID - TABLE 2*NOTE: Property codes marked withan asterisk will always be the same.DO NOT RESIDE ON FEDERAL PROPERTYBUT: (1) HAVE A PARENT ON ACTIVE DUTY IN THE UNIFORMED SERVICESOFFICIAL NAME, ADDRESS, CITY, STATE(2)(1)NUMBERPROPERTY CODETABLE 1-1. FEDERAL PROPERTY ON WHICH CHILDREN WITH DISABILITIES RESIDENUMBER OFCHILDRENON SURVEYDATE(3)TABLE 1: CHILDREN WITH DISABILITIES WHO: (1) RESIDE ON ELIGIBLE FEDERAL PROPERTY AND HAVE A PARENT ON ACTIVE DUTY IN THE UNIFORMED SERVICESOF THE UNITED STATES; OR (2) RESIDE ON ELIGIBLE FEDERAL PROPERTY WITH A PARENT WHO IS BOTH AN ACCREDITED FOREIGN GOVERNMENTOFFICIAL AND A FOREIGN MILITARY OFFICER; OR(3) RESIDE ON ELIGIBLE INDIAN LANDS(Include only children enrolled in State-approved special education programs on thistable. Exclude these children from Tables2,3,4, and 5.)APPLICATION FOR IMPACT AID SECTION 8003 - TABLE 1(2)TABLE 3 TOTAL =>NUMBER OFCHILDREN ONSURVEY DATE(5)PROPERTY CODENUMBER(3) (4)FEDERAL PROPERTY ON WHICH CHILDREN RESIDE FEDERAL PROPERTY ON WHICH PARENTS ARE EMPLOYEDOFFICIAL NAME, ADDRESS, CITY, STATE OFFICIAL NAME, ADDRESS, CITY, STATEProperties listed on this page were claimed in the LEA's prior year application. An LEA may add any property it believes is eligible, without a property code number.However, it must indicate the specific location of each parcelof claimed property (i.e., the official name, street address, city and state).PROPERTY CODENUMBER(1)TABLE 3:CHILDREN WHO: (1) RESIDE ON FEDERAL PROPERTYWITH A PARENT EMPLOYED ON ELIGBLE FEDERALPROPERTY LOCATED AT LEAST PARTLY WITHINTHE SCHOOLDISTRICT; OR (2) RESIDE ON ELIGIBLE FEDERAL PROPERTY AND HAVEA PARENT ON ACTIVE DUTY IN THE UNIFORMED SERVICES OF THE UNITEDSTATES; OR (3)RESIDE ON ELIGIBLE FEDERAL PROPERTY AND HAVE A PARENT WHO ISBOTH AN ACCREDITED FOREIGN GOVERNMENT OFFICIAL AND A FOREIGN MILITARY OFFICER;OR (4) RESIDE ON ELIGIBLE INDIAN LANDS (NO PARENTAL EMPLOYMENT REQUIRED) (Do not includechildren reported on Table 1.)APPLICATION FOR IMPACT AID SECTION 8003 - TABLE 3PAGE: 4-1PAGE: 5-1FEDERAL PROPERTY ON WHICH CHILDREN RESIDE FEDERAL PROPERTY ON WHICH PARENTS ARE EMPLOYED(4)PROPERTY CODENUMBER(1)(3)NUMBER OFCHILDRENON SURVEYDATE(6)OFFICIAL NAME, ADDRESS, CITY, STATE(5)OFFICIAL NAME, ADDRESS, CITY, STATE(2)TABLE 4 TOTAL => TABLE 5 TOTAL =>TABLE 4.NUMBER OFCHILDRENON SURVEYDATEPROPERTY CODENUMBERCHILDREN WHO RESIDE ON ELIGIBLE FEDERAL PROPERTY BUT WHOSE PARENTSARE NOT EMPLOYED ON FEDERAL PROPERTY(Children residing on eligible Indian lands should be reported on Table 3.)However, it must indicate the specific location of each parcel of claimed property (i.e., the official name, street address, city and state).Properties listed on this page were claimed in the LEA's prioryear application. An LEA may add any property it believes is eligible, without a property code number.CHILDREN WHO DO NOT RESIDE ON FEDERAL PROPERTY BUT: (1) RESIDE WITH APARENT EMPLOYED ON FEDERAL PROPERTY; OR (2) HAVE A PARENT ON ACTIVE DUTYIN THE UNIFORMED SERVICES OF THE UNITED STATES; OR (3) HAVE A PARENT WHO ISBOTH AN ACCREDITED FOREIGN GOVERNMENT OFFICIAL AND A FOREIGN MILITARYOFFICER (Do not include children reported on Table 2.)TABLE 5.APPLICATION FOR IMPACT AID SECTION 8003 - TABLES 4 AND 5Total federally connected children claimed for the current year (2012-2013) from tables 1through 5.PAGE: 6TABLE 6. MEMBERSHIP AND AVERAGE DAILY ATTENDANCE DATA3.3.2. (B)preceding school year summer school ADA(Enter zero if not applicable.)(B)2. (A)preceding regular school year ADA of all children reported on line 1.(E) of this table(This line INCLUDES tuition-out children and EXCLUDES tuition-in children.)(Summer school ADA SHOULD NOT be included in this line.)(A)Average daily attendance (ADA) for the preceding school year (2011-2012)(ADA is defined as the aggregate number of days in attendance of all students during aschool year divided by the number ofdays school is in session during that year(section 14101(1) of the ESEA).)2.1. (E)1. (D)1. (C)1. (B)1. (A)for whom the applicant school district provided free public elementary or secondaryeducation [line 1.(C) PLUS line 1.(D)]for whom tuition was paid (tuition-out)subtotal [line 1.(A) MINUS line 1.(B)]for whom tuition is received (tuition-in)in schools of the applicant's district(Do not include tuition-out children)(A)(B)(C)(D)(E)Membership - total number of children enrolled in the preceding school year and the currentschool year on the respective survey date1.PRECEDINGYEAR2011-2012CURRENTYEAR2012-2013APPLICATION FOR IMPACT AID SECTION 8003 - TABLE 6APPLICANT'S PRECEDING FISCAL YEAR(2011-2012) ACTUAL AMOUNTTABLE 7. FISCAL REPORT ON EXPENDITURES OF ADDITIONAL FUNDS PROVIDED FORCHILDREN WITH DISABILITIESFiscal Report for applicants claiming children on Tables 1 and 2 of the applicant's previous fiscal year's applicationITEMTotal ADDITIONAL expenditures for all childrenwith disabilities (DO NOT include expendituresfor gifted and talented children or expendituresfor the regular education costs of children withdisabilities.) Such costs may include facilities modification costs (i.e., ramps, etc.), additionaladministrative costs, assessment costs, counselors or social workers, special teachers, aidesand other staff, transportation,homebound and/or hospital programs.1.1. $2.Total State aid for all current operating expenditures for elementary and secondary educationpurposes (Include State aid for State-approved education programs for children withdisabilities.)2. $3.Total State aid for children with disabilities (DONOT include State aid for gifted and talentedchildren.)3. $4.Total funds from Part B of the Individuals with Disabilities Education Act (IDEA, 20 U.S.C. 1400et seq.)4. $Total membership enrolled in State-approvededucation programs for all children withdisabilities (Include all children, both federally-connected and non-federally connected, withcurrent signed individualized education programs(IEP's) in effect ON THE IDEA COUNT DATE.DO NOT include gifted and talented children.)6.6.ED USE ONLY: TCE ________________LCR ________________5.Other sources of aid received for children with disabilities (Medicaid, etc.)5. $PAGE: 7APPLICATION FOR IMPACT AID SECTION 8003 - TABLE 71 2 3 4 56Excellent Good AdequateFair Poor ReplaceTABLE 10 - a. FISCAL REPORT ON EXPENDITURESOF ALL CONSTRUCTION-RELATED FUNDS AND ACCOUNTSTABLE 10. SECTION 8007 (CONSTRUCTION)Fiscal report for applicants that received section 8007 funds inthe previous year. These funds must be used for construction-related activities. Typically these funds are depositedin either a capital fund, building fund or debt service fund account.1. Opening Balance for All Construction-Related Funds or Accounts2.Section 8007 Receipts3.Other Receipts4.Transfers In1. $2. $3. $4. $APPLICANT'S PRECEDING FISCAL YEAR(2011-2012) ACTUAL AMOUNTITEMPAGE: 9New or easily restorable to "like new" condition: only minimal routine maintenance required.Excellent:Good:Only routine maintenance or repair required.Adequate: Some preventive maintenanceand/or corrective repair required.Fair:Fails to meet code and functional requirements in some cases;failure(s) are inconvenient; extensive corrective maintenance andrepair required.Poor:Consistent Substandard performance; failure(s) are disruptive and costly; fail most code and functional requirements; require constant attention, renovation,or replacement.Replace: Non-operational or significantly substandard performance. Replacement required.Rating ScalePlease rate the overall condition of your LEA's facilities. Refer to the rating scale shown below and circle one. Overall condition refers to both physical condition and the ability ofthe buildings to meet the functional requirements of the instructional programs.TABLE 10 - b. REPORT ON CONDITION OF FACILITIESTotal Expenditures for Construction or Renovation, including:the preparation of drawings and specifications for school facilities, erecting, building, acquiring,altering, remodeling, repairing,or extending school facilities, and inspecting and supervising theconstruction of school facilities8. Total Expenditures for Debt Service9.Closing Balance for all Construction-Related Funds or Accounts8. $9. $7.Transfers OutNon-Construction-Related Expenditures (See Instructions)6.5.7. $6. $5. $APPLICATION FOR IMPACT AID SECTION 8003 - TABLE 10OMBNo.1810‐0687Exp.9/30/2014MilitaryorIndianLandsHousingUndergoingRenovationorRebuildingIfyouwanttheImpactAidProgramtoconsiderhousingonamilitaryinstallationoronIndianlandsthatistemporarilyunavailableforoccupancybecauseitisundergoingrenovationorrebuilding,youmustsubmittheHousingOfficialContactInformationFormwithyourSection8003ImpactAidapplication.TheImpactAidProgramwillcontactthehousingofficialidentifiedonthisformtodeterminewhethersomenumberofchildrenwhodonotresideintheseunitsmaybecategorizedasthoughtheyresideonamilitaryinstallationorIndianlandsincalculatingpaymentsforthisapplication.ContacttheImpactAidProgrambyphoneat(202)260‐1357orviaemailatImpact.Aid@ed.govifyouneedmoreinformationaboutthisrequirement.Attachment:Title:File:FormCompleteHousing Undergoing Renovation or RebuildingMILITARYORINDIANLANDSHOUSINGUNDERGOINGRENOVATIONORREBUILDINGUpload