### APPLICATION FOR DEPARTMENT OF DEFENSE IMPACT AID FOR CHILDREN WITH SEVERE DISABILITIES FOR SCHOOL YEAR 2012-2013 

## FY 2014 OMB No. 0704-0425 OMB approval expires

E-MAIL THIS APPLICATION TO : DoDEA.impactaid@hq.dodea.edu or FAX TO : Department of Defense Education Activity Attn: Impact Aid

(770) 268-7498 DEFINITION OF SEVERELY DISABLED A student whose disabilities involve extensive mental, physical and/or behavioral impairment, or a combination of multiple impairments, likely to be permanent in nature and greatly compromising an individual's ability to function independently in the community, perform self-care, and obtain employment, in accordance with State rules implementing the Individuals with Disabilities Education Act, as amended, 20 U.S.C. 1400 et seq., and for whom the local education agency is providing more special education and related services than are provided for children with mild and moderate disabilities in special education programs. ELIGIBILITY CRITERIA A local education agency (LEA) is eligible for financial assistance for severely disabled military dependent students under 20 U.S.C. 7703a, if 1) the LEA provides a free and appropriate education (FAPE) to two or more such children with severe disabilities, and 2) if the LEA incurs individual costs for providing that FAPE that exceed (a) five times the national or State average per pupil expenditure (whichever is lower) for a special education (SPED) program that is located outside the boundaries of the school district of the LEA that pays for the FAPE of the studennt, or (b) three times the State average per pupil expenditure for a SPED program offered by the LEA, or within the boundaries of the school district served by the LEA. 1.a. NAME OF LOCAL EDUCATION AGENCY (LEA) b. ADDRESS (Include ZIP Code)
2. Enter the national or State average per pupil expenditure (whichever is lower) used 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. 3. Enter the State average per pupil expenditure used 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. 4. Enter the total number of military dependent children in your district, for whom you are applying for a payment in this application, who meet the given definition of severe disability and whose cost for their educational and related services meets the eligibility criteria above. A minimum of two students must be claimed for eligibility purposes.

5. PERSON COMPLETING THIS APPLICATION a. NAME (Last, First, Middle Initial) b. TITLE c. TELEPHONE NUMBER (Include Area Code) d. E-MAIL ADDRESS 6. CERTIFICATION I certify that I have read the information contained in this application and have found that all of the data included in this application is, to the best of my knowledge and belief, true, complete, and accurate. I certify that I am authorized to make the representations and commitments in this applicaton, for and on behalf of the applicant and otherwise act as the applicant's authorized representative in submitting this application for funding under section 363 of P.L. 106-398 (National Defense Authorization Act for Fiscal Year 2001), as amended. a. NAME OF CERTIFYING OFFICIAL (Last, First, Middle Initial) b. SIGNATURE c. E-MAIL ADDRESS d. DATE SIGNED (YYYYMMDD) 

### SD FORM 816, 20131114 DRAFT Page 1 of 3 Pages Adobe Designer 9.0 

### SECTION I - APPLICANT INFORMATION AND CERTIFICATION

PREVIOUS EDITION IS OBSOLETE. The public reporting burden for this collection of information is estimated to average 8 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100 (0704-0425). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

a. Of the total number of military dependent children listed in 4 above, enter the number of children that were residing in base housing or in military installation housing undergoing renovation or rebuilding, and are deemed as eligible for on base housing. b. Of the total number of military dependent children listed in 4 above, enter the number of children that were residing in off base housing. 

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### SD FORM 816, 20131114 DRAFT Page 2 of 3 Pages 

### SECTION II - PAYMENT DETERMINATION 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



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### SD FORM 816, 20131114 DRAFT Page 3 of 3 Pages 

### SECTION III - FINANCIAL ORGANIZATION DIRECT DEPOSIT INFORMATION

PLEASE E-MAIL THIS APPLICATION TO : DoDEA.impactaid@hq.dodea.edu or FAX TO : Department of Defense Education Activity Attn: Impact Aid (770) 268-7498 If your LEA is eligible to receive payment under the Impact Aid for Children with Severe Disabilities Program, please submit the following information on your financial organization. INCOMPLETE OR INACCURATE INFORMATION WILL DELAY PROCESSING AND PAYMENT. 1. NAME OF LOCAL EDUCATIONAL AGENCY (LEA)

3. NAME OF FINANCIAL ORGANIZATION

4. ADDRESS OF FINANCIAL ORGANIZATION (Include ZIP Code)

5. ROUTING TRANSIT NUMBER
6. YOUR AGENCY'S ACCOUNT NUMBER
7. FEDERAL TAX IDENTIFICATION NUMBER (Required by our disbursing agent)
8. NAME OF PERSON TO CONTACT (Last, First, Middle Initial)
9. TITLE OF PERSON TO CONTACT

10. TELEPHONE NUMBER (Include Area Code) 

### APPLICATION FOR DEPARTMENT OF DEFENSE IMPACT AID FOR CHILDREN WITH SEVERE DISABILITIES FOR SCHOOL YEAR 2012-2013 

## FY 2014

2. ACTIVE DUNS NUMBER ( www.sam.gov ) 

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### $65,000

$1,480 

# S A M P L E

SD FORM 816, 20131114 DRAFT SECTION II - PAYMENT DETERMINATION 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

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## X 

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