SD FORM 816C, 20131114 DRAFT Page SECTION II - PAYMENT DETERMINATION (Continuation Page)

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PREVIOUS EDITION IS OBSOLETE.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 

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# D R A F TSample Copy SECTION II - PAYMENT DETERMINATION (Continuation Page)

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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 

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