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

FY 2014

APPLICATION FOR DEPARTMENT OF DEFENSE
IMPACT AID FOR CHILDREN WITH SEVERE DISABILITIES
FOR SCHOOL YEAR 2012-2013 (Continuation Page)

OMB No. 0704-0425
OMB approval expires

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

N E E D S

D D

6 7

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.)

SD FORM 816C, 20131121 DRAFT

PREVIOUS EDITION IS OBSOLETE.

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Adobe Designer 9.0

FY 2014

APPLICATION FOR DEPARTMENT OF DEFENSE
IMPACT AID FOR CHILDREN WITH SEVERE DISABILITIES
FOR SCHOOL YEAR 2012-2013 (Continuation Page)

OMB No. 0704-0425
OMB approval expires

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:

N E E D S
X

D D

2

6 7

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

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.

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.)

SD FORM 816C, 20131121 DRAFT

$65,000

$1,480

Sample Copy