SD FORM 816C, 20131114 DRAFT Page

SECTION II - PAYMENT DETERMINATION (Continuation Page)

of Pages

OMB No. 0704-0425 

OMB approval expires 

PREVIOUS EDITION IS OBSOLETE.

INSTRUCTIONS

1. In order to determine the amount the LEA is eligible to receive for each military 

dependent child with a severe disability, you will need to complete a page 2 to compute 

special education and related services costs for each such child for the applicable school 

year. Enter the number of children you are identifying on this form in box 1. If the costs 

are the same for two or more children, enter the number of children with that same set of 

costs in box 1, and complete one page 2 for that group.These children must meet the 

given definition of severe disability as stated on page 1. Next, mark an "X" in box 1.a. or 

1.b. to declare which cost eligibility applies:

a. Exceeds costs by five times the national or State average per pupil expenditure (whichever is lower), for 

a military dependent child who is provided educational and related services under a program that is located 

outside the boundaries of the school district of the LEA that pays for the FAPE of the student, or

b. Exceeds costs by three times the State average per pupil expenditure for a military dependent child who 

is provided educational and related services under a program offered by the LEA, or within the boundaries 

of the school district served by the LEA.

2. The costs associated with the special education and related services of the military

dependent children with severe disabilities are as follows:

Enter the actual payment made on behalf of the child with a severe disability that

meets the criteria of 1.a. or 1.b. above.

3. Enter the amount received from sources other than the State, the Individuals with

Disabilities Education Act, or Federal Impact Aid (e.g., Medicaid) to defray the costs 

of educational and related services to the child which are received due to the 

presence of a severe disabling condition. (Required for award processing.)

APPLICATION FOR DEPARTMENT OF DEFENSE 

IMPACT AID FOR CHILDREN WITH SEVERE DISABILITIES 

 FOR SCHOOL YEAR 2012-2013

FY 2014

Adobe Designer 9.0

D R A F T
Sample Copy

SECTION II - PAYMENT DETERMINATION (Continuation Page)

$65,000

$1,480

S A M P L E

SD FORM 816C, 20131114 DRAFT

INSTRUCTIONS

1. In order to determine the amount the LEA is eligible to receive for each military

dependent child with a severe disability, you will need to complete a page 2 to compute 

special education and related services costs for each such child for the applicable school 

year. Enter the number of children you are identifying on this form in box 1. If the costs 

are the same for two or more children, enter the number of children with that same set of 

costs in box 1, and complete one page 2 for that group. These children must meet the 

given definition of severe disability as stated on page 1. Next, mark an "X" in box 1.a. or 

1.b. to declare which cost eligibility applies:

a. Exceeds costs by five times the national or State average per pupil expenditure (whichever is lower), for 

a military dependent child who is provided educational and related services under a program that is located 

outside the boundaries of the school district of the LEA that pays for the FAPE of the student, or

b. Exceeds costs by three times the State average per pupil expenditure for a military dependent child who 

is provided educational and related services under a program offered by the LEA, or within the boundaries 

of the school district served by the LEA.

2. The costs associated with the special education and related services of the military

dependent children with severe disabilities are as follows:

Enter the actual payment made on behalf of the child with a severe disability that

meets the criteria of 1.a. or 1.b. above.

3. Enter the amount received from sources other than the State, the Individuals with

Disabilities Education Act, or Federal Impact Aid (e.g., Medicaid) to defray the costs 

of educational and related services to the child which are received due to the 

presence of a severe disabling condition. (Required for award processing.)

APPLICATION FOR DEPARTMENT OF DEFENSE 

IMPACT AID FOR CHILDREN WITH SEVERE DISABILITIES 

 FOR SCHOOL YEAR 2012-2013

FY 2014

2

X

OMB No. 0704-0425 

OMB approval expires 

D R A F T