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.

D R A F T
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

D R A F T
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)

D R A F T
Sample Page 2 of 3 Pages

$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

2

X

D R A F T