1810-0687 Section 8003 Application for Impact Aid

Final Filing Date:

01/31/2013

Applicants must submit complete
applications (ED Form 4019) on or before
this filing deadline to receive full
payments. See the instructions for
further information.

U.S. Department of Education
Impact Aid Program
Washington, D.C. 20202-6244

APPLICATION FOR IMPACT AID - SECTION 8003
Submit an original and 1 copy to the Impact Aid Program.
Send 1 copy to the State Educational Agency (SEA) using the attached transmittal form.

MEMBERSHIP SURVEY DATE
First (Required) :
Second (Optional) :

2014
IMPACT AID # :

SURVEY FORMS :

ORIGINAL APPLICATION :

SOURCE CHECK :

AMENDMENT :

APPLICANT NAME :

CONTACT PERSON NAME :

STREET/P.O. BOX :

TITLE :

CITY :

PHONE :

COUNTY :

FAX :

STATE & ZIP :

E-MAIL :

PR/AWARD # :
DUNS # :

CHECK TO APPLY FOR FUNDING UNDER SECTION 8003(b)(2) FOR HEAVILY IMPACTED LEAs. (If you check this box, the Impact Aid Program will contact
you to request additional information.)
GRADE SPAN MAINTAINED

LEGAL CLASSIFICATION (If different from grade span)

I certify that I have read the statements contained in this application and that these statements and all of the data included in this application are, to the best of my knowledge and
belief, true, complete, and correct. I certify that I am authorized to make the representations and commitments in this application, for and on behalf of the applicant and otherwise to
act as the applicant's authorized representative in submitting this application for funding under section 8003 of the Impact Aid Program (Title VIII of the Elementary and Secondary
Education Act). I declare that the applicant will mail a complete copy of this application to the SEA at the same time that it mails this application to the U.S. Department of Education.

NAME AND TITLE OF AUTHORIZED REPRESENTATIVE (Please type or print.)

SIGNATURE

PAGE: 1

DATE

APPLICATION FOR IMPACT AID - SECTION 8003

IMPACT AID PROGRAM ASSURANCES AND CERTIFICATIONS
The applicant local educational agency (LEA) hereby declares that it has filed the following assurances and certifications covering the Impact Aid Program (Title VIII of the Elementary
and Secondary Education Act (ESEA)) with the U.S. Department of Education, and, as of the date of the signature below, reaffirms and incorporates by reference those assurances and
certifications in this Impact Aid application.* The LEA certifies that no circumstances affecting the validity of the following assurances have changed since their previous filing:
•

As applicable, the assurances in OMB Standard Form 424B (Assurances for Non-Construction Programs), relating to legal authority to apply for assistance; access to
records; conflict of interest; merit systems; nondiscrimination; Hatch Act provisions; labor standards; flood insurance; environmental standards; wild and scenic river
systems; historic preservation; protection of human subjects; animal welfare; lead-based paint; Single Audit Act; and general agreement to comply with all Federal laws,
executive orders and regulations;

•

The certification regarding lobbying in ED Form 80-0013; and

•

With respect to the Certification Regarding Lobbying, the LEA recertifies that no Federal appropriated funds have been paid or will be paid to any person for influencing or
attempting to influence an officer or employee of Congress, or an employee of a Member of Congress in connection with the making or renewal of Federal grants under this
program; that the LEA will complete and submit Standard Form LLL, "Disclosure Form to Report Lobbying," when required (34 CFR Part 82, Appendix B); and that the LEA
will require the full certification, as set forth in 34 CFR Part 82, Appendix A, in the award documents for all subawards at all tiers.

The LEA further assures that:
•
•

It is a local educational agency that was created and authorized to operate schools, has administrative control and direction of free public education in the school districts,
and that it may legally accept and disburse Federal funds to aid in financing its expenditures;
It will comply with all applicable statutes, regulations, and requirements concerning this grant, including requirements of the Impact Aid law (Title VIII of the ESEA), the
program regulations (34 CFR Part 222), and program administrative requirements;

•

It will use fiscal control and fund accounting procedures that will ensure proper disbursement of, and accounting for any Impact Aid payments received for federally
connected children with disabilities claimed on Tables 1 and 2, and will use those funds to provide a free appropriate public education to those children in accordance with
the Individuals with Disabilities Education Act (IDEA) (20 U.S.C., 1400 et seq.). The special education programs provided to the children with disabilities claimed in this
application conform to the policies, procedures and requirements of the (IDEA);

•

For any children claimed who reside on eligible Indian lands, policies and procedures have been established as required by section 8004 of the Impact Aid law, and have
been adequately disseminated to the tribes and parents of children residing on eligible Indian lands. A copy of the current policies and procedures or a waiver statement
from the local Indian tribe(s) is attached (see instructions for further information); and

•

It is hereby advised that, under section 8011 of the Impact Aid law, it is entitled to request an administrative hearing on, and/or review or reconsideration of, any action of the
Department under the Impact Aid law that adversely affects or aggrieves the applicant; any such requests are governed by the regulations in 34 CFR Part 222, Subpart J,
except for requests for hearings concerning Indian policies and procedures, tribal complaints, and withholdings that are governed by the regulations at 34 CFR Part 222,
Subpart G. Any request for a hearing, review or reconsideration under 34 CFR Part 222, Subpart J, must be made in writing and submitted within 60 calendar days from the
date of the applicant's notice (receipt) of the adverse action to: Director, Impact Aid Program, United States Department of Education, 400 Maryland Ave., SW, Washington,
D.C. 20202-6244.

*If the applicant is applying for Impact Aid assistance for the first time, the applicant also must file with the Impact Aid Program by the deadline for filing this application the following
assurances and certification that it can obtain from the IAP: OMB Standard Form 424B (Assurances for Non-Construction Programs) and ED Form 80-0013 (certification regarding
lobbying).

SIGNATURE:

DATE:
PAGE: 2

APPLICATION FOR IMPACT AID SECTION 8003 - TABLE 1
TABLE 1: CHILDREN WITH DISABILITIES WHO: (1) RESIDE ON ELIGIBLE FEDERAL PROPERTY AND HAVE A PARENT ON ACTIVE DUTY IN THE UNIFORMED SERVICES
OF THE UNITED STATES; OR (2) RESIDE ON ELIGIBLE FEDERAL PROPERTY WITH A PARENT WHO IS BOTH AN ACCREDITED FOREIGN GOVERNMENT
OFFICIAL AND A FOREIGN MILITARY OFFICER; OR (3) RESIDE ON ELIGIBLE INDIAN LANDS
(Include only children enrolled in State-approved special education programs on this table. Exclude these children from Tables 2,3,4, and 5.)
TABLE 1-1. FEDERAL PROPERTY ON WHICH CHILDREN WITH DISABILITIES RESIDE
PROPERTY CODE
NUMBER
(1)

OFFICIAL NAME, ADDRESS, CITY, STATE
(2)

NUMBER OF
CHILDREN
ON SURVEY
DATE
(3)

TABLE 1-2. CHILDREN WITH DISABILITIES
PROPERTY CODE
NUMBER
(4)

CHILDREN WITH DISABILITIES
(5)

0000-0010*

WITH A PARENT ON ACTIVE DUTY IN THE
UNIFORMED SERVICES OF THE UNITED STATES

0000-0015*

WITH A PARENT WHO IS BOTH AN ACCREDITED
FOREIGN GOVERNMENT OFFICIAL AND A FOREIGN
MILITARY OFFICER

1435-0010*

RESIDING ON ELIGIBLE INDIAN LANDS

*NOTE: Property codes marked with an asterisk will always be the same.

NUMBER OF
CHILDREN ON
SURVEY DATE
(6)

TABLE 1-2 TOTAL = >

NOTE: TABLE 1-1 TOTAL AND TABLE 1-2
TOTAL MUST BE THE SAME.
TABLE 1-2 IS A SUMMARY OF ALL
CHILDREN ON TABLE 1-1.
Properties listed on this page were claimed in the LEA's prior year application.
An LEA may add any property it believes is eligible, without a property code number.
However, it must indicate the specific location of each parcel of claimed
property (i.e., the official name, street address, city, and state).

TABLE 1-1 TOTAL = >
APPLICATION FOR IMPACT AID - TABLE 2

TABLE 2: CHILDREN WITH DISABILITIES WHO DO NOT RESIDE ON FEDERAL PROPERTY BUT: (1) HAVE A PARENT ON ACTIVE DUTY IN THE UNIFORMED SERVICES
OF THE UNITED STATES; OR (2) HAVE A PARENT WHO IS BOTH AN ACCREDITED FOREIGN GOVERNMENT OFFICIAL AND A FOREIGN MILITARY OFFICER
(Include only children enrolled in state-approved special education programs on this table. Exclude these children from Tables 1, 3, 4, and 5.)
PROPERTY CODE NUMBER
CHILDREN WITH DISABILITIES
NUMBER OF CHILDREN ON SURVEY DATE
(1)
(2)
(3)
0000-0010*

WITH A PARENT ON ACTIVE DUTY IN THE
UNIFORMED SERVICES OF THE UNITED STATES

0000-0015*

WITH A PARENT WHO IS BOTH AN ACCREDITED FOREIGN
GOVERNMENT OFFICIAL AND A FOREIGN MILITARY OFFICER

TABLE 2 TOTAL = >
PAGE: 3-1

APPLICATION FOR IMPACT AID SECTION 8003 - TABLE 3
TABLE 3: CHILDREN WHO: (1) RESIDE ON FEDERAL PROPERTY WITH A PARENT EMPLOYED ON ELIGBLE FEDERAL PROPERTY LOCATED AT LEAST PARTLY WITHIN THE SCHOOL
DISTRICT; OR (2) RESIDE ON ELIGIBLE FEDERAL PROPERTY AND HAVE A PARENT ON ACTIVE DUTY IN THE UNIFORMED SERVICES OF THE UNITED STATES; OR (3)
RESIDE ON ELIGIBLE FEDERAL PROPERTY AND HAVE A PARENT WHO IS BOTH AN ACCREDITED FOREIGN GOVERNMENT OFFICIAL AND A FOREIGN MILITARY OFFICER;
OR (4) RESIDE ON ELIGIBLE INDIAN LANDS (NO PARENTAL EMPLOYMENT REQUIRED) (Do not include children reported on Table 1.)
FEDERAL PROPERTY ON WHICH CHILDREN RESIDE
PROPERTY CODE
NUMBER
(1)

OFFICIAL NAME, ADDRESS, CITY, STATE
(2)

FEDERAL PROPERTY ON WHICH PARENTS ARE EMPLOYED
PROPERTY CODE
NUMBER
(3)

OFFICIAL NAME, ADDRESS, CITY, STATE
(4)

NUMBER OF
CHILDREN ON
SURVEY DATE
(5)

TABLE 3 TOTAL =>
Properties listed on this page were claimed in the LEA's prior year application. An LEA may add any property it believes is eligible, without a property code number.
However, it must indicate the specific location of each parcel of claimed property (i.e., the official name, street address, city and state).
PAGE: 4-1

APPLICATION FOR IMPACT AID SECTION 8003 - TABLES 4 AND 5
TABLE 5. CHILDREN WHO DO NOT RESIDE ON FEDERAL PROPERTY BUT: (1) RESIDE WITH A
PARENT EMPLOYED ON FEDERAL PROPERTY; OR (2) HAVE A PARENT ON ACTIVE DUTY
IN THE UNIFORMED SERVICES OF THE UNITED STATES; OR (3) HAVE A PARENT WHO IS
BOTH AN ACCREDITED FOREIGN GOVERNMENT OFFICIAL AND A FOREIGN MILITARY
OFFICER (Do not include children reported on Table 2.)

TABLE 4. CHILDREN WHO RESIDE ON ELIGIBLE FEDERAL PROPERTY BUT WHOSE PARENTS
ARE NOT EMPLOYED ON FEDERAL PROPERTY
(Children residing on eligible Indian lands should be reported on Table 3.)

FEDERAL PROPERTY ON WHICH CHILDREN RESIDE
PROPERTY CODE
NUMBER

OFFICIAL NAME, ADDRESS, CITY, STATE

(1)

(2)

NUMBER OF
CHILDREN
ON SURVEY
DATE
(3)

FEDERAL PROPERTY ON WHICH PARENTS ARE EMPLOYED
PROPERTY CODE
NUMBER

OFFICIAL NAME, ADDRESS, CITY, STATE

(4)

(5)

TABLE 4 TOTAL =>

TABLE 5 TOTAL =>

Properties listed on this page were claimed in the LEA's prior year application. An LEA may add any property it believes is eligible, without a property code number.
However, it must indicate the specific location of each parcel of claimed property (i.e., the official name, street address, city and state).
PAGE: 5-1

NUMBER OF
CHILDREN
ON SURVEY
DATE
(6)

APPLICATION FOR IMPACT AID SECTION 8003 - TABLE 6

TABLE 6. MEMBERSHIP AND AVERAGE DAILY ATTENDANCE DATA
PRECEDING
YEAR
2011-2012

1. Membership - total number of children enrolled in the preceding school year and the current
school year on the respective survey date
(A)

in schools of the applicant's district (Do not include tuition-out children)

1. (A)

(B)

for whom tuition is received (tuition-in)

1. (B)

(C)

subtotal [line 1.(A) MINUS line 1.(B)]

1. (C)

(D)

for whom tuition was paid (tuition-out)

1. (D)

(E)

for whom the applicant school district provided free public elementary or secondary
education [line 1.(C) PLUS line 1.(D)]

1. (E)

CURRENT
YEAR
2012-2013

2. Average daily attendance (ADA) for the preceding school year (2011-2012)
(ADA is defined as the aggregate number of days in attendance of all students during a
school year divided by the number of days school is in session during that year
(section 14101(1) of the ESEA).)
(A)

preceding regular school year ADA of all children reported on line 1.(E) of this table
(This line INCLUDES tuition-out children and EXCLUDES tuition-in children.)
(Summer school ADA SHOULD NOT be included in this line.)

2. (A)

(B)

preceding school year summer school ADA
(Enter zero if not applicable.)

2. (B)

3. Total federally connected children claimed for the current year (2012-2013) from tables 1
through 5.
3.

PAGE: 6

APPLICATION FOR IMPACT AID SECTION 8003 - TABLE 7

TABLE 7. FISCAL REPORT ON EXPENDITURES OF ADDITIONAL FUNDS PROVIDED FOR
CHILDREN WITH DISABILITIES
Fiscal Report for applicants claiming children on Tables 1 and 2 of the applicant's previous fiscal year's application
APPLICANT'S PRECEDING FISCAL YEAR
ITEM
(2011-2012) ACTUAL AMOUNT
1.

Total ADDITIONAL expenditures for all children with disabilities (DO NOT include expenditures
for gifted and talented children or expenditures for the regular education costs of children with
disabilities.) Such costs may include facilities modification costs (i.e., ramps, etc.), additional
administrative costs, assessment costs, counselors or social workers, special teachers, aides
and other staff, transportation, homebound and/or hospital programs.

1. $

2.

Total State aid for all current operating expenditures for elementary and secondary education
purposes (Include State aid for State-approved education programs for children with
disabilities.)

2. $

3.

Total State aid for children with disabilities (DO NOT include State aid for gifted and talented
children.)

3. $

4.

Total funds from Part B of the Individuals with Disabilities Education Act (IDEA, 20 U.S.C. 1400
et seq.)

4. $

5.

Other sources of aid received for children with disabilities (Medicaid, etc.)

5. $

6.

Total membership enrolled in State-approved education programs for all children with
disabilities (Include all children, both federally-connected and non-federally connected, with
current signed individualized education programs (IEP's) in effect ON THE IDEA COUNT DATE.
DO NOT include gifted and talented children.)

6.
ED USE ONLY: TCE ________________
LCR ________________

PAGE: 7

APPLICATION FOR IMPACT AID SECTION 8003 - TABLE 10

TABLE 10. SECTION 8007 (CONSTRUCTION)
TABLE 10 - a. FISCAL REPORT ON EXPENDITURES OF ALL CONSTRUCTION-RELATED FUNDS AND ACCOUNTS
Fiscal report for applicants that received section 8007 funds in the previous year. These funds must be used for construction-related activities. Typically these funds are deposited
in either a capital fund, building fund or debt service fund account.
APPLICANT'S PRECEDING FISCAL YEAR
(2011-2012) ACTUAL AMOUNT

ITEM
1.

$

2.

Opening Balance for All Construction-Related Funds or Accounts
Section 8007 Receipts

2.

$

3.

Other Receipts

3.

$

4.

Transfers In

4.

$

5.

Transfers Out

5.

$

6.

Non-Construction-Related Expenditures (See Instructions)

6.

$

7.

Total Expenditures for Construction or Renovation, including:
the preparation of drawings and specifications for school facilities, erecting, building, acquiring,
altering, remodeling, repairing, or extending school facilities, and inspecting and supervising the
construction of school facilities

7.

$

8.

Total Expenditures for Debt Service

8.

$

9.

Closing Balance for all Construction-Related Funds or Accounts

9.

$

1.

TABLE 10 - b. REPORT ON CONDITION OF FACILITIES
Please rate the overall condition of your LEA's facilities. Refer to the rating scale shown below and circle one. Overall condition refers to both physical condition and the ability of
the buildings to meet the functional requirements of the instructional programs.

Rating Scale
Excellent:
Good:
Adequate:
Fair:
Poor:

New or easily restorable to "like new" condition: only minimal routine maintenance required.
Only routine maintenance or repair required.
Some preventive maintenance and/or corrective repair required.
Fails to meet code and functional requirements in some cases; failure(s) are inconvenient; extensive corrective maintenance and repair required.
Consistent Substandard performance; failure(s) are disruptive and costly; fail most code and functional requirements; require constant attention, renovation,
or replacement.

Replace:

Non-operational or significantly substandard performance. Replacement required.

Excellent
1

Good
2

Adequate
3

Fair
4
PAGE: 9

Poor
5

Replace
6

OMB No. 1810‐0687 Exp. 9/30/2014 

Housing Undergoing Renovation or Rebuilding
MILITARY OR INDIAN LANDS HOUSING UNDERGOING RENOVATION OR REBUILDING 

Military or Indian Lands Housing Undergoing Renovation or Rebuilding

If you want the Impact Aid Program to consider housing on a military installation or on Indian lands that is 
temporarily unavailable for occupancy because it is undergoing renovation or rebuilding, you must submit the 
Housing Official Contact Information Form with your Section 8003 Impact Aid application.  The Impact Aid Program 
will contact the housing official identified on this form to determine whether some number of children who do not 
reside in these units may be categorized as though they reside on a military installation or Indian lands in 
calculating payments for this application.  Contact the Impact Aid Program by phone at (202)260‐1357 or via email 
at Impact.Aid@ed.gov if you need more information about this requirement. 
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