Spreadsheet: 0dbb86b0-c957-4544-bf89-3ae1bbebc818
Sheet: CapExpendDisAccessRev

 |  |  | Division of School Finance                            1500 Highway 36 West                          Roseville, MN  55113-4266 |  |  | CAPITAL EXPENDITURE DISABLED ACCESS REVENUE |  |  |  | ED-02081-21
 |  |  |  |  |  | LEVY AUTHORITY APPLICATION |  |  |  | DUE: 07/22/2014
GENERAL INFORMATION AND INSTRUCTIONS:  Pursuant to Minnesota Statutes, section  123B.58, a school district must submit this application to the Minnesota
Department of Education (MDE) to receive levy authority for revenue to be used for the costs of removing architectural barriers.  A district’s maximum disabled
[NAME] for taxes payable in 2015 may not exceed the approved expenditure for the district’s architectural barrier removal projects, less the funds available
or to be made available.  The total levy may not cumulatively exceed the total available and may be spread over a time period not to exceed 8 years.  E-mail this
completed application to Lonn.Moe@State.[NAME].  Questions regarding this form should be directed to [NAME] at (651) 582-8569.
IDENTIFICATION INFORMATION
District Name: |  |  |  |  |  |  | District Number: |  | District Type:
Name of District Contact Person: |  |  |  |  | Title: |  | Telephone Number: |  | E-Mail Address:
Name of Person Completing Access Audit: |  |  |  |  |  |  | Telephone Number: |  | E-Mail Address:
ARCHITECTURAL BARRIER REMOVAL AUDIT/COST ESTIMATE INFORMATION
Provide, BY BUILDING NAME and FISCAL YEAR, the total actual/estimated expenditures for architectural barrier removal projects.  Estimates should include the cost
for engineering/design specifications, labor, facility audit/transition planning, materials, and other related expenditures.  Make additional copies of this page BEFORE
entering data if your district has more than 10 buildings involved.
 | BUILDING NAME |  |  |  | ESTIMATED MARKET VALUE | Fiscal Year 1992-2013 ACTUAL EXPENDITURE | Fiscal Year 2014 ACTUAL/ ESTIMTED EXPENDITURE | Fiscal Year 2015 ESTIMATED EXPENDITURE | Fiscal Year 2016 ESTIMATED EXPENDITURE | TOTALS:                Fiscal Years                         1992 - 2016
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11 | Sub-Total from Additional Sheets
12 | DISTRICT-WIDE PROJECT COSTS
COMPUTATION OF 2014 PAYABLE 2015 LEVY LIMIT
1 | Total FY 1992 through 2016 district-wide project costs (from line 12):
2 | [NAME] is $300,000, OR for districts that have combined or consolidated since June 30, 1991, the maximum is
 | is (number of districts as of June 1991 x $150,000):
3 | Lesser of Line 1 or 2:
4 | Total of Payable 1993 through 2014 Disabled Access Levies:
5 | Payable 2015 Disabled Access Levy Limit (Line 3 minus [NAME]):                                              if negative, enter 0
6 | Amount of Payable 2015 [NAME] (cannot exceed line 5):
BUILDING AND BARRIER REMOVAL PROJECTS INFORMATION
 | DATE OF ORIGINAL BUILDING COMPLETION |  | DATE OF LATES ADDITION OR MAJOR REMODELING |  | [NAME] OF PROPOSED BUILDING MODIFICATIONS  (Note: Please list building modification(s) in order or priority for each building/project.)
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APPLICANT DISTRICT ACTIVITY STATUS
The items below are based on Section 504 and/or the Americans with Disabilities Act (ADA).  Please provide your district's status by checking the applicable response to each item.
 | YES | NO | CURRENTLY IN PROCESS |  | THE APPLICANT DISTRICT HAS:
 |  |  |  |  | Designated a Section 504/ADA coordinator.
 |  |  |  |  | Completed a Section 504/ADA self-evaluation.
 |  |  |  |  | Provided public notification (multi-media) regarding the district's requirement not to discriminate against persons with
 |  |  |  |  | disabilities
 |  |  |  |  | Reviewed communication materials to determine modifications, resources and equipment to ensure "effective
 |  |  |  |  | communication" ("interpreters/large print, TTY/TDD assisted listening, etc.).
 |  |  |  |  | Developed and implemented a Section 504/ADA district plan.
 |  |  |  |  | Reviewed programs, policies and procedures to ensure nondiscrimination.
 |  |  |  |  | Sought persons with disabilities to help the review, planning and implementation process.
 |  |  |  |  | Reviewed all structures, sites, owned and leased, for compliance with required accessibility and building codes.
 |  |  |  |  | Developed a facility transition plan based on survey data from all buildings in the district.
 |  |  |  |  | Developed and practiced emergency evacuation plans for individuals with disabilities in case of a fire or other disaster.
VERIFICATION OF DATA AND [NAME]
 |  |  | I hereby verify the information provided on this application is true and accurate to the best of my knowledge and belief, and further, assure the following:
 |  |  | - | data reflects planned project cost estimates and/or actual expenditures incurred by the districts,
 |  |  | - | that other program modifications have been considered (e.g., moving classrooms),
 |  |  | - | planned modifications are based on current facility survey data/transition plans, and,
 |  |  | - | currently, these facilities fit into district/facility plans for at least five years.
Signature - Superintendent/Responsibility Authority |  |  |  |  |  | Title |  |  | Date
End of worksheet