Form Secretary of Defen Secretary of Defen Application for Department of Defense Impact Aid for Chi

APPLICATION FOR DEPARTMENT OF DEFENSE
IMPACT AID FOR CHILDREN WITH SEVERE DISABILITIES
FOR SCHOOL YEAR 2004-2005

FY 2006

OMB No. 0704-0425
OMB approval expires

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, Executive Services Directorate (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.

E-MAIL THIS APPLICATION TO: [email protected]
FAX THE SIGNATURE SHEET ONLY TO:
Office of the Under Secretary of Defense (Personnel and Readiness)
Attn: Impact Aid
(703) 588-0661

SECTION I - APPLICANT INFORMATION AND CERTIFICATION
DEFINITION OF SEVERE DISABILITY
Children with severe disabilities means children with disabilities who because of the intensity of their physical, mental, or emotional
problems need highly specialized education, social, psychological, and medical services in order to maximize their full potential for
useful and meaningful participation in society and for self-fulfillment. The term includes those children with disabilities with severe
emotional disturbance (including schizophrenia), autism, severe and profound mental retardation, and those who have two or more
serious disabilities such as deaf-blindness, mental retardation and blindness, and cerebral palsy and blindness.
ELIGIBILITY CRITERIA
Under 20 U.S.C. 7703a, the local education agency (LEA) is eligible to receive a payment for a child described in subparagraph
(A)(ii), (B), (D)(i) or (D)(ii) of section 8003(a)(1) of the Elementary and Secondary Education Act (ESEA) of 1965, as amended (20
U.S.C. 7703(a)(1)) if the LEA serves two or more such children with severe disabilities, for costs incurred in providing a free and
appropriate education (FAPE) to each such child, where payment to be made only on behalf of children whose individual educational
or related services cost exceeds either (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 student, 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)

NEEDS DD 67

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. 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.
5. PERSON COMPLETING THIS APPLICATION
a. NAME (Last, First, Middle Initial)
c. TELEPHONE NUMBER (Include Area Code)

b. TITLE
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

SD FORM 816, 20060706 DRAFT

d. DATE SIGNED (YYYYMMDD)
PREVIOUS EDITION IS OBSOLETE.

Page 1 of 3 Pages
FormFlow/Adobe Professional 7.0

APPLICATION FOR DEPARTMENT OF DEFENSE

FY 2006

IMPACT AID FOR CHILDREN WITH SEVERE DISABILITIES
FOR SCHOOL YEAR 2004-2005

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:

NEEDS DD 67
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.
SD FORM 816, 20060706 DRAFT

Page 2 of 3 Pages

APPLICATION FOR DEPARTMENT OF DEFENSE
IMPACT AID FOR CHILDREN WITH SEVERE DISABILITIES

FY 2006

FOR SCHOOL YEAR 2004-2005

SECTION III - FINANCIAL ORGANIZATION DIRECT DEPOSIT INFORMATION
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)

2. NAME OF FINANCIAL ORGANIZATION

3. ADDRESS OF FINANCIAL ORGANIZATION (Include ZIP Code)

NEEDS DD 67
4. ROUTING TRANSIT NUMBER

5. YOUR AGENCY'S ACCOUNT NUMBER

6. FEDERAL TAX IDENTIFICATION NUMBER (Required by our disbursing agent)

7. NAME OF PERSON TO CONTACT (Last, First, Middle Initial)

8. TITLE OF PERSON TO CONTACT

9. TELEPHONE NUMBER (Include Area Code)

PLEASE E-MAIL THIS APPLICATION TO:
[email protected]
FAX THE SIGNATURE SHEET ONLY TO:
Office of the Under Secretary of Defense (Personnel and Readiness)
Attn: Impact Aid
(703) 588-0661
SD FORM 816, 20060706 DRAFT

Page 3 of 3 Pages

APPLICATION FOR DEPARTMENT OF DEFENSE

FY 2006

IMPACT AID FOR CHILDREN WITH SEVERE DISABILITIES
FOR SCHOOL YEAR 2004-2005

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

2

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:

NEEDS DD 67
a. Exceeds costs by five times the national or State average per pupil expenditure (whichever is lower), for

X

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

S A M P L E

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.

$65,000

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

$1,480

presence of a severe disabling condition.
SD FORM 816, 20060706 DRAFT

Sample Page 2 of 3 Pages