U.S. Department of Education

Impact Aid Program

Washington, D.C. 20202-6244

PAGE: 1

Final Filing Date: 

GRADE SPAN MAINTAINED LEGAL CLASSIFICATION (If different from grade s

01/31/2013

Submit an original and 1 copy to the Impact Aid Program.

 APPLICATION FOR IMPACT AID - SECTION 8003 

Send 1 copy to the State Educational Agency (SEA) using the attached transmittal form.

Applicants must submit complete applications (ED Form 4019) on or beforethis filing deadline to receive full payments. See the instructions for further information.

APPLICANT NAME :

STREET/P.O. BOX : 

CITY :

COUNTY :

STATE & ZIP :

MEMBERSHIP SURVEY DATE 

First (Required) :

Second (Optional) :

IMPACT A

DUN

SURVEY FORMS : ORIGINAL APPLICATION :

SOURCE CHECK : AMENDMENT :

PR/AWAR

CHECK TO APPLY FOR FUNDING UNDER SECTION 8003(b)(2) FOR HEAVILY IMPACTED LEAs. (If you check this box, the Impact A

you to request additional information.)

NAME AND TITLE OF AUTHORIZED REPRESENTATIVE (Please type or print.) SIGNATURE I certify that I have read the statements contained in this application and that these statements and all of the data included in this application are, to t

belief, true, complete, and correct. I certify that I am authorized to make the representations and commitments in this application, for and on behalf o

act as the applicant's authorized representative in submitting this application for funding under section 8003 of the Impact Aid Program (Title VIII of tEducation Act). I declare that the applicant will mail a complete copy of this application to the SEA at the same time that it mails this application to th

CONTACT PERSON NAME : 

TITLE : 

PHONE : 

FAX : 

E-MAIL : 
PAGE: 2

The applicant local educational agency (LEA) hereby declares that it has filed the following assurances and certifications covering the Impact Aid Pro

and Secondary Education Act (ESEA)) with the U.S. Department of Education, and, as of the date of the signature below, reaffirms and incorporates b

certifications in this Impact Aid application.* The LEA certifies that no circumstances affecting the validity of the following assurances have changed 

 • • • • • • •

 •

*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 filassurances and certification that it can obtain from the IAP: OMB Standard Form 424B (Assurances for Non-Construction Programs) and ED Form 80lobbying).

SIGNATURE: DATE: 

IMPACT AID PROGRAM ASSURANCES AND CERTIFICATI

It 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 recDepartment under the Impact Aid law that adversely affects or aggrieves the applicant; any such requests are governed by the regulations in except for requests for hearings concerning Indian policies and procedures, tribal complaints, and withholdings that are governed by the reSubpart G. Any request for a hearing, review or reconsideration under 34 CFR Part 222, Subpart J, must be made in writing and submitted wdate of the applicant's notice (receipt) of the adverse action to: Director, Impact Aid Program, United States Department of Education, 400 MD.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 been adequately disseminated to the tribes and parents of children residing on eligible Indian lands. A copy of the current policies and procfrom 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 paymenconnected children with disabilities claimed on Tables 1 and 2, and will use those funds to provide a free appropriate public education to thothe Individuals with Disabilities Education Act (IDEA) (20 U.S.C., 1400 et seq.). The special education programs provided to the children with application 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 the Impact Aid law program 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 edand 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 or will be paid to attempting to influence an officer or employee of Congress, or an employee of a Member of Congress in connection with the making or reneprogram; that the LEA will complete and submit Standard Form LLL, "Disclosure Form to Report Lobbying," when required (34 CFR Part 82, will 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 authority to apply 

records; conflict of interest; merit systems; nondiscrimination; Hatch Act provisions; labor standards; flood insurance; environmental stand

systems; historic preservation; protection of human subjects; animal welfare; lead-based paint; Single Audit Act; and general agreement to 

executive orders and regulations;

APPLICATION FOR IMPACT AID - SECTION 8003 
PAGE: 3-1

(2) 

CHILDREN WITH DISABILITIES NUMBER 

(1)

PROPERTY CODE NUMBER 

(5) 

TABLE 1-2. CHILDREN WITH DISABILITIES

CHILDREN WITH DISABILITIES PROPERTY CODE

NUMBER

(4)

TABLE 1-1 TOTAL = >

0000-0010*0000-0015*

1435-0010* 

WITH A PARENT ON ACTIVE DUTY IN THE UNIFORMED SERVICES OF THE UNITED STATES

WITH A PARENT WHO IS BOTH AN ACCREDITED FOREIGN GOVERNMENT OFFICIAL AND A FOREIGN MILITARY OFFICERRESIDING ON ELIGIBLE INDIAN LANDS

property (i.e., the official name, street address, city, and 

Properties listed on this page were claimed in the LEA's An LEA may add any property it believes is eligible, with

However, it must indicate the specific location of each p

NOTE: TABLE 1-1 TOTAL AND T

TOTAL MUST BE THE SATABLE 1-2 IS A SUMMARCHILDREN ON TABLE 1-

TABLE 

CHILDREN WITH DISABILITIES WHOOF THE UNITED STATES; OR (2) HAVE A PARENT WHO IS BOTH AN ACCREDITED FOREIGN GOVERNMENT OFFICIAL AND A FOREIGN M

(Include only children enrolled in state-approved special education programs on this table. Exclude these children from Tables 1, 3, 4, and 

TABLE 2: 

0000-0010* 0000-0015* 

WITH A PARENT ON ACTIVE DUTY IN THE UNIFORMED SERVICES OF THE UNITED STATESWITH A PARENT WHO IS BOTH AN ACCREDITED FOREIGN GOVERNMENT OFFICIAL AND A FOREIGN MILITARY OFFICER

TABLE 2 TOTAL = >

APPLICATION FOR IMPACT AID - TABLE 2 

*NOTE: Property codes marked with an asterisk will always be the same.

DO NOT RESIDE ON FEDERAL PROPERTY BUT: (1) HAVE A PARENT ON ACTIVE DUTY IN THE UN

OFFICIAL NAME, ADDRESS, CITY, STATE

(1) (2)

NUMBER

PROPERTY CODE

TABLE 1-1. FEDERAL PROPERTY ON WHICH CHILDREN WITH DISABILITIES RESIDE

NUMBER OF

CHILDREN

ON SURVEY

DATE

(3)

TABLE 1: CHILDREN WITH DISABILITIES WHO: (1) RESIDE ON ELIGIBLE FEDERAL PROPERTY AND HAVE A PARENT ON ACTIVE DUTY IN THE UNIF

OF THE UNITED STATES; OR (2) RESIDE ON ELIGIBLE FEDERAL PROPERTY WITH A PARENT WHO IS BOTH AN ACCREDITED FOREIGN GOFFICIAL AND A FOREIGN MILITARY OFFICER; OR (3) RESIDE ON ELIGIBLE INDIAN LANDS(Include only children enrolled in State-approved special education programs on this table. Exclude these children from Tables 2,3,4, and 5.)

APPLICATION FOR IMPACT AID SECTION 8003 - TABLE 1
(2)

TABLE 3 TOT

PROPERTY CODE

NUMBER

(3) (4)

FEDERAL PROPERTY ON WHICH CHILDREN RESIDE FEDERAL PROPERTY ON WHICH PARENTS ARE EMPLOYED

OFFICIAL NAME, ADDRESS, CITY, STATE OFFICIAL NAME, ADDRESS, CITY, STAT

Properties listed on this page were claimed in the LEA's prior year application. An LEA may add any property it believes is eligible, wHowever, it must indicate the specific location of each parcel of claimed property (i.e., the official name, street address, city and state

PROPERTY CODE

NUMBER

(1)

TABLE 3: CHILDREN WHO: (1) RESIDE ON FEDERAL PROPERTY WITH A PARENT EMPLOYED ON ELIGBLE FEDERAL PROPERTY LOCATED AT LEA

DISTRICT; OR (2) RESIDE ON ELIGIBLE FEDERAL PROPERTY AND HAVE A PARENT ON ACTIVE DUTY IN THE UNIFORMED SERVICES OF 

RESIDE ON ELIGIBLE FEDERAL PROPERTY AND HAVE A PARENT WHO IS BOTH AN ACCREDITED FOREIGN GOVERNMENT OFFICIAL AN

OR (4) RESIDE ON ELIGIBLE INDIAN LANDS (NO PARENTAL EMPLOYMENT REQUIRED) (Do not include children reported on Table 1.)

APPLICATION FOR IMPACT AID SECTION 8003 - TABLE 3

PAGE: 4-1
PAGE: 5-1

FEDERAL PROPERTY ON WHICH CHILDREN RESIDE FEDERAL PROPERTY ON WHICH PARENTS ARE E

(4)

PROPERTY CODE

NUMBER

(1) (3)

OFFICIAL NAME, ADDRESS

(5)

OFFICIAL NAME, ADDRESS, CITY, STATE

(2)

TABLE 4 TOTAL => TA

TABLE 4.

NUMBER OF

CHILDREN

ON SURVEY

DATE

PROPERTY CODE

NUMBER

CHILDREN WHO RESIDE ON ELIGIBLE FEDERAL PROPERTY BUT WHOSE PARENTS ARE 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 prior year application. An LEA may add any property it believes is eligible, without a pro

CHILDREN WHO DO NOT RESIDE ON FEDERAL PROPARENT EMPLOYED ON FEDERAL PROPERTY; OR IN THE UNIFORMED SERVICES OF THE UNITED STABOTH AN ACCREDITED FOREIGN GOVERNMENT OFOFFICER (Do not include children reported on Table 

TABLE 5. 

APPLICATION FOR IMPACT AID SECTION 8003 - TABLES 4 AND 5
Total federally connected children claimed for the current year (2012-2013) from tables 1 

through 5.

PAGE: 6

TABLE 6. MEMBERSHIP AND AVERAGE DAILY ATTENDANCE D

3. 

preceding school year summer school ADA 2. (B)(Enter zero if not applicable.)

(B)

preceding regular school year ADA of all children reported on line 1.(E) of this table 2. (A)(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 of days 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 secondary education [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)

(A) in schools of the applicant's district (Do not include tuition-out children)(B)(C)(D)(E)Membership - total number of children enrolled in the preceding school year and the current school year on the respective survey date

1.

PRECEDING

YEAR

2011-2012

APPLICATION FOR IMPACT AID SECTION 8003 - TABLE 6
APPLICANT'S PR

(2011-2012) 

TABLE 7. FISCAL REPORT ON EXPENDITURES OF ADDITIONAL FUNDS P

CHILDREN WITH DISABILITIES

Fiscal Report for applicants claiming children on Tables 1 and 2 of the applicant's previous fiscal year's application

ITEM

Total ADDITIONAL expenditures for all children with disabilities (DO NOT include expenditures for gifted and talented children or expenditures for the regular education costs of children with disabilities.) Such costs may include facilities modification costs (i.e., ramps, etc.), additional administrative costs, assessment costs, counselors or social workers, special teachers, aides and other staff, transportation, homebound and/or hospital programs.

1. 1. $

2. Total State aid for all current operating expenditures for elementary and secondary education 

purposes (Include State aid for State-approved education programs for children with disabilities.)

2. $

3. Total State aid for children with disabilities (DO NOT include State aid for gifted and talented 

children.)

3. $

4. Total funds from Part B of the Individuals with Disabilities Education Act (IDEA, 20 U.S.C. 1400 

et seq.)

4. $

Total membership enrolled in State-approved education programs for all children with disabilities (Include all children, both federally-connected and non-federally connected, with current 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: 

 L

5. Other sources of aid received for children with disabilities (Medicaid, etc.) 5. $

PAGE: 7

APPLICATION FOR IMPACT AID SECTION 8003 - TABLE 7
 1 2 3 4 5 6 

 Excellent Good Adequate Fair Poor Replace

TABLE 10 - a. FISCAL REPORT ON EXPENDITURES OF ALL CONSTRUCTION-RELATED FUNDS AND ACCOUNTS

TABLE 10. SECTION 8007 (CONSTRUCTION)

Fiscal report for applicants that received section 8007 funds in the previous year. These funds must be used for construction-related activities. Typicin 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 In

1. $2. $3. $4. $

APPLICANT'S PRECEDING 

(2011-2012) ACTUAL 

ITEM

PAGE: 9

Excellent: New or easily restorable to "like new" condition: only minimal routine maintenance required.Good: Only routine maintenance or repair required.Adequate: Some preventive maintenance and/or corrective repair required.Fair: Fails to meet code and functional requirements in some cases; failure(s) are inconvenient; extensive corrective maintenance and repa

Poor: Consistent Substandard performance; failure(s) are disruptive and costly; fail most code and functional requirements; require consta

or replacement.

Replace: Non-operational or significantly substandard performance. Replacement required.

Rating Scale

Please rate the overall condition of your LEA's facilities. Refer to the rating scale shown below and circle one. Overall condition refers to both physic

the buildings to meet the functional requirements of the instructional programs.

TABLE 10 - b. REPORT ON CONDITION OF FACILITIES 

Total 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 the 

construction of school facilities

8. Total Expenditures for Debt Service9. Closing Balance for all Construction-Related Funds or Accounts

8. $9. $

7.

Transfers Out

6. Non-Construction-Related Expenditures (See Instructions)5.

7. $6. $5. $

APPLICATION FOR IMPACT AID SECTION 8003 - TABLE 10
OMB No. 1810‐0687 Exp. 9/30/2014

Military or Indian Lands Housing Undergoing Renovation or RebuildingIf you want the Impact Aid Program to consider housing on a military installation or on Indian lands that istemporarily unavailable for occupancy because it is undergoing renovation or rebuilding, you must submit theHousing Official Contact Information Form with your Section 8003 Impact Aid application. The Impact Aid Programwill contact the housing official identified on this form to determine whether some number of children who do notreside in these units may be categorized as though they reside on a military installation or Indian lands incalculating payments for this application. Contact the Impact Aid Program by phone at (202)260‐1357 or via emailat Impact.Aid@ed.gov if you need more information about this requirement.Attachment:Title:File:

Form Complete

Housing Undergoing Renovation or Rebuilding 

MILITARY OR INDIAN LANDS HOUSING UNDERGOING RENOVATION OR REBUILDING

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