Application for Impact Aid Section 8003 Tables 1-11

Impact Aid, Sec. 8003 Table 1 - Live-on & Work-on, CWD

OMB No.1810-NEW Exp._ _/_ _/_ _ _ _

Application For Impact Aid Section 8003 - Table 1
Applicant Name:
Table 1:

Impact Aid Number:

School Year:

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

Official Name, Address, City, State

Property Type

(1)

(2)

(3)

Table 1-1 Total =>

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Number of children on
survey date
(4)

Impact Aid, Sec. 8003 Table 1 - Live-on & Work-on, CWD

Table 1-2. Children with disabilities
Property Code
Number
(4)

Number of children
on survey date
(6)

Children with disabilities
(5)
With a parent on active duty in the uniformed services of the United States
With a parent who is both an accredited foreign government official and a foreign military officer
Residing on eligible Indian lands
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).

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Impact Aid, Sec. 8003 Table 2 - Live-off, CWD

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Application For Impact Aid Section 8003 - Table 2
Applicant Name:
Table 2:

Impact Aid Number:

School Year:

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
(1)

Children with disabilities
(2)

Number of children on survey date
(3)

With a parent on active duty in the uniformed services of the United States
With a parent who is both an accredited foreign government official and a foreign
military officer
Table 2 Total =>

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Impact Aid, Sec. 8003 Table 3 - Live-on & Work-on

OMB No.1810-NEW Exp._ _/_ _/_ _ _ _

Application For Impact Aid Section 8003 - Table 3
Applicant Name:
Table 3:

Impact Aid Number:

School Year:

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 Tables 1.)
Federal Property on which children reside
Property Code
Number
(1)

Federal Property on which parents are employed

Official Name, Address, City, State

Property Code
Number

Official Name, Address, City, State

(2)

(3)

(4)

Table 3 Total =>
Properties listed on this page were claimed in the LEA's prior year application. An LEA may add 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).

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Number
of
children
on
survey
date
(5)

Impact Aid, Sec. 8003 Table 4 - Live-on & Low-Rent Housing

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Application For Impact Aid Section 8003 - Table 4
Applicant Name:
Table 4.

Impact Aid Number:

School Year:

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

Number of
children on
survey date

(1)

(2)

(3)

Table 4 Total =>
Properties listed on this page were claimed in the LEA's prior year application. An LEA may add 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).

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Impact Aid, Sec. 8003 Table 5 - Work-on

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Application For Impact Aid Section 8003 - Table 5
Applicant Name:
Table 5.

Impact Aid Number:

School Year:

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.)
Federal Property on which parents are employed

Property Code
Number

Official Name, Address, City, State

Number of
children on
survey date

(1)

(2)

(3)

Table 5 Total =>
Properties listed on this page were claimed in the LEA's prior year application. An LEA may add 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).

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Impact Aid, Sec. 8003 Table 6 - Membership & ADA

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Table 6. Membership and Average Daily Attendance Data
Applicant Name:

1.

2.

Impact Aid Number:

Membership - 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.)
(B) For whom tuition is received (Tuition-in)
(C) Subtotal [Line 1.(A) minus Line 1.(B)]
(D) For whom tuition was paid (Tuition-out)
(E) Total for whom the applicant school district provided free public elementary or secondary
education [Line 1.(C) plus Line 1.(D)]

Preceding
Year

Current
Year

1.(A)
1.(B)
1.(C)
1.(D)
1.(E)

Average daily attendance (ADA) for the preceding school year:
(ADA is defined by section 14101(1) of the Elementary and Secondary Education Act 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.)
(A) Preceding regular school year ADA of children reported on Line 1.(E) of this table
This line includes tuition-out children and excludes tuition-in children.
(Do not include summer school ADA on this line.)
(B) Hours of summer school attendance for the preceding school year
(C) Number of days in the regular school year

3.

School Year:

Total federally connected children claimed for the current year (_ _ _ _ - _ _ _ _) from Tables 1
through 5.

2.(A)

2.(B)
2.(C)

3.

Precentage [Line 3 divided by Line 1.(E) Current Year]

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%

Impact Aid, Sec. 8003 Table 7 - Expenditures for CWD

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Table 7. Fiscal Report on expenditures of additional funds provided for children with disabilities
Applicant Name:

Impact Aid Number:

School Year:

Fiscal report for applicants claiming children on Tables 1 and 2 of the applicant's preceding fiscal year's application.
Applicant's preceding fiscal year
actual amount

Item
$

1.

Total Additional expenditures of all children with disabilities
Such expenditures may include facilities modification costs (e.g., ramps and accessible rest rooms),
additional administrative costs, assessment costs, counselors or social workers, special teachers, aides
and other staff, transportation, homebound programs and hospital programs. (Do not include
expenditures for gifted and talented children or the regular education programs for children with
disabilities.)

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.)

$

3.

Total State aid for children with disabilities
(Do not include State aid for gifted and talented children.)

$

4.

Total funds for Part B of the Individuals with Disabilities Education Act
(IDEA, USC 1400 et seq.)

$

5.

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

$

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 (IEPs) in effect on the IDEA Count Date. Do not include
gifted and talented children.)

ED use
only:

TCE
LCR

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Impact Aid, Sec. 8003 Table 8 - ED-owned Schools

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Table 8. Children who attend schools owned by the U.S. Department of Education
Applicant Name:

Impact Aid Number:

School Year:

Report on this table children of members of the U.S. uniformed services included in Tables 1, 2, 3 and 5 who
were attending school on the survey date in a school building owned by the U.S. Department of Education.
Student counts from this table will be used in the calculations of payments under section 8007(a), Formula
Construction payments.

(Col. 1)
Name of School Building Owned by the U.S. Department of
Education

(Col. 2)
Total Number of Children
Enrolled in This Building on
Survey Date on Cover Page

(Col. 3)
Number of U.S. Uniformed
Services Children Reported
on Table 1 or 3 Who
Attended This School on
Survey Date

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(Col. 4)
Number of U.S. Uniformed
Services Children Reported
on Table 2 or 5 Who
Attended This School on
Survey Date

Impact Aid, Sec. 8003 Table 9 - Military Installation Housing

OMB No.1810-NEW Exp._ _/_ _/_ _ _ _

Table 9. Military installation housing units undergoing renovation or rebuilding
Applicant Name:

Impact Aid Number:

School Year:

Include the housing units undergoing renovation or rebuilding on impact aid survey date shown on the cover page of
this application. For each unit, list the specific address or quarters number, the number of school aged children expected
to reside in housing unit, the date the housing unit was vacated or demolished, and, if applicable, the date funds
became available for rebuilding the demolished housing. Documentation of the availability of funding must be provided
for housing being rebuilt.
(Col. 1)
Specific Addresses or Quarters Numbers for the Housing
Undergoing Renovation or Rebuilding

Name of Military Installation

(Col. 2)
No. of School-aged Children
Expected to Reside in This
Housing When Renovation or
Rebuilding is Complete

(Col. 3)
Date Unit Vacated or
Demolished

(Col. 4)
If Unit Demolished, Date
Funds Became Available for
Rebuilding (Provide
Documentation)

Base Housing Occupancy Rate: %

I hereby certify that the above information is accurate and complete to the best of knowledge and the total number of
children reported would have resided in the on-base housing listed above except that the housing was undergoing renovation
or rebuilding on the Impact Aid survey date.
Signature

Date

Name and Title of Military Housing Official

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Telephone Number

Impact Aid, Sec. 8003 Table 10 - Expenditure for Construction

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Table 10. Section 8007 (Construction)
Applicant Name:

Impact Aid Number:

School Year:

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 a debt service
fund account.
Item
1.
2.
3.
4.
5.
6.
7.

Opening Balance for All Construction-Related Funds or Accounts
Section 8007 Receipts
Other Receipts
Transfers In
Transfers Out
Non-Construction-Related Expenditures (See Instructions)
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
8. Total Expenditures for Debt Service
9. Closing Balance for all Construction-Related Funds or Accounts

Applicant's preceding fiscal year
( 2005 - 2006 )
1. $
2. $
3. $
4. $
5. $
6. $
7. $

8. $
9. $

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 instructional programs.
Rating Scale
Excellent : New or easily restorable to "like new" condition: only minimal routine maintenance required.
Good :
Only routine maintenance or minor repair required.
Adequate : Some preventive maintenance and/or corrective repair required.
Fair :
Fails to meet code and functional requirement in some cases; failure(s) are inconvenient; extensive corrective maintenance
and repair required.
Poor :
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.

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Impact Aid, Sec. 8003 Table 11 - Indian Housing Renovation

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Table 11. Housing on Indian Lands undergoing renovation or rebuilding
Applicant Name:

Impact Aid Number:

School Year:

List of housing located on Indian lands undergoing renovation on Impact Aid survey date shown on the cover page of
this application by name, address, and type and identity the number of school-aged children associated with this housing.
(Col. 1)
(Col. 2)
(Col. 3)
(Col. 4)
Name (and Number, if Applicable) of Specific Address or Legal Description for Each House Type of Indian Lands Where Housing Number of SchoolHousing Development or Project
or Unit Undergoing Renovation or Rebuilding
is Located(Trust, Restricted, ANCSA, aged Children Who
Undergoing Renovation or Rebuilding
or Other Eligible Indian Lands)
Last Resided in This
Housing

Certification by Housing or Tribal Official: I hereby certify that the information reported above is accurate and that
the number of children listed in column 4 would have resided in this housing on Indian lands except that the housing
was undergoing renovation or rebuilding on the survey date.
Signature

Date

Name and Title of Housing or Tribal Official

Telephone Number

Certification by Bureau of Indian Affairs or Tribal Official: I hereby certify that I have reviewed official records and
have verified that this housing is located on Indian Lands as defined in sections 8013(5)(A)(ii) and 8013(7) of the Impact
Aid Law. (See the application instructions for definitions.)

Signature

Date

Name and Title of BIA or Tribal Official

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Telephone Number