Section 7002 Impact Aid Section 7002 Application

Final Filing Date: _ _/_ _/_ _ _ _
Applicants must submit complete
applications on or
before this filing deadline to receive
full payments. See the instructions
for further information.

U.S. Department of Education
Impact Aid Program

Form Approved:

Washington, DC. 20202-6244

-Expiration date: _ _/_ _/_ _ _ _

-OMB number 1810-0036

APPLICATION FOR IMPACT AID - SECTION 7002
Submit an original to the Impact Aid Program.
Send 1 copy to the State Educational Agency (SEA) using the attached transmittal form.

ORIGINAL APPLICATION: 

DUNS NUMBER

PR/AWARD NUMBER

IMPACT AID NUMBER

AMENDMENT: 
APPLICANT NAME:

CONTACT PERSON NAME:

STREET/P.O. BOX:

TITLE:

CITY:

PHONE:

COUNTY:

FAX:

STATE & ZIP:

E-MAIL:



CHECK IF THE NUMBER OF ACRES OF ANY ELIGIBLE 7002 PROPERTY HAVE CHANGED SlNCE THE LAST FILING FOR IMPACT AID FUNDING. *

 CHECK IF THE APPLICANT'S BOUNDARIES HAVE CHANGED SINCE THE LAST FILING FOR IMPACT AID FUNDING. *
* If you check either of these boxes, the Impact Aid Program will contact you to request additional information.
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 7002 of the Impact Aid Program (Title VII 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

DATE

ASSURANCES ‐ NON‐CONSTRUCTION PROGRAMS
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including 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 the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of
Management and Budget, Paperwork Reduction Project (0348‐0040), Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE
SPONSORING AGENCY.
NOTE: Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the awarding agency. Further, certain
Federal awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be notified.
As the duly authorized representative of the applicant, I certify that the applicant:
1.
2.
3.
4.
5.
6.

7.

8.
9.
10.
11.

12.
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18.

Has the legal authority to apply for Federal assistance and the institutional, managerial and financial capability (including funds sufficient to pay the non‐
Federal share of project cost) to ensure proper planning, management and completion of the project described in this application.
Will give the awarding agency, the Comptroller General of the United States and, if appropriate, the State, through any authorized representative, access
to and the right to examine all records, books, papers, or documents related to the award; and will establish a proper accounting system in accordance
with generally accepted accounting standards or agency directives.
Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or
organizational conflict of interest, or personal gain.
Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency.
Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. §§4728‐4763) relating to prescribed standards for merit systems for programs
funded under one of the 19 statutes or regulations specified in Appendix A of OPM's Standards for a Merit System of Personnel Administration (5 C.F.R.
900, Subpart F).
Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88‐
352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C.
§§1681‐ 1683, and 1685‐1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C.
§794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. §§6101‐6107), which
prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92‐255), as amended, relating to nondiscrimination
on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91‐616), as
amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) §§523 and 527 of the Public Health Service Act of 1912 (42 U.S.C.
§§290 dd‐3 and 290 ee‐3), as amended, relating to confidentiality of alcohol and drug abuse patient records; (h) Title VII of the Civil Rights Act of 1968 (42
U.S.C. §§3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (i) any other nondiscrimination provisions in
the specific statute(s) under which application for Federal assistance is being made; and, (j) the requirements of any other nondiscrimination statute(s)
which may apply to the application.
Will comply, or has already complied, with the requirements of Titles II and III of the Uniform Relocation Assistance and Real Property Acquisition Policies
Act of 1970 (P.L. 91‐646) which provide for fair and equitable treatment of persons displaced or whose property is acquired as a result of Federal or
federally‐assisted programs. These requirements apply to all interests in real property acquired for project purposes regardless of Federal participation in
purchases.
Will comply, as applicable, with provisions of the Hatch Act (5 U.S.C. §§1501‐1508 and 7324‐7328) which limit the political activities of employees whose
principal employment activities are funded in whole or in part with Federal funds.
Will comply, as applicable, with the provisions of the Davis‐ Bacon Act (40 U.S.C. §§276a to 276a‐7), the Copeland Act (40 U.S.C. §276c and 18 U.S.C. §874),
and the Contract Work Hours and Safety Standards Act (40 U.S.C. §§327‐ 333), regarding labor standards for federally‐assisted construction subagreements.
Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93‐234) which
requires recipients in a special flood hazard area to participate in the program and to purchase flood insurance if the total cost of insurable construction
and acquisition is $10,000 or more.
Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of environmental quality control measures
under the National Environmental Policy Act of 1969 (P.L. 91‐190) and Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO
11738; (c) protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of
project consistency with the approved State management program developed under the Coastal Zone Management Act of 1972 (16 U.S.C. §§1451 et seq.);
(f) conformity of Federal actions to State (Clean Air) Implementation Plans under Section 176(c) of the Clean Air Act of 1955, as amended (42 U.S.C. §§7401
et seq.); (g) protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended (P.L. 93‐523); and, (h) protection
of endangered species under the Endangered Species Act of 1973, as amended (P.L. 93‐205).
Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. §§1271 et seq.) related to protecting components or potential components of the
national wild and scenic rivers system.
Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 U.S.C. §470), EO
11593 (identification and protection of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. §§469a‐1 et seq.).
Will comply with P.L. 93‐348 regarding the protection of human subjects involved in research, development, and related activities supported by this award
of assistance.
Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89‐544, as amended, 7 U.S.C. §§2131 et seq.) pertaining to the care, handling, and
treatment of warm blooded animals held for research, teaching, or other activities supported by this award of assistance.
Will comply with the Lead‐Based Paint Poisoning Prevention Act (42 U.S.C. §§4801 et seq.) which prohibits the use of lead‐based paint in construction or
rehabilitation of residence structures.
Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act Amendments of 1996 and OMB Circular
No. A‐133, "Audits of States, Local Governments, and Non‐Profit Organizations."
Will comply with all applicable requirements of all other Federal laws, executive orders, regulations, and policies governing this program.

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ASSURANCES – IMPACT AID PROGRAMS
The LEA further assures that:
1.
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;
2.
It will comply with all applicable statutes, regulations, and requirements concerning this grant, including requirements of the Impact Aid law (Title VII
of the ESEA), the program regulations (34 CFR Part 222), and program administrative requirements;
3.
It is hereby advised that, under section 7011 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.

CERTIFICATIONS REGARDING
LOBBYING
Certification for Contracts, Grants, Loans, and Cooperative Agreements
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an
officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the
awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee
of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant,
loan, or cooperative agreement, the undersigned shall complete and submit Standard Form‐LLL, ''Disclosure of Lobbying Activities,'' in accordance with its
instructions.
(3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts,
subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a
material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for
making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil
penalty of not less than $10,00 0 and not more than $100,000 for each such failure.
Statement for Loan Guarantees and Loan Insurance
The undersigned states, to the best of his or her knowledge and belief, that: If
any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an
officer or employee of Congress, or an employee of a Member of Congress in connection with this commitment providing for the United States to insure or guarantee
a loan, the undersigned shall complete and submit Standard Form‐LLL, ''Disclosure of Lobbying Activities,'' in accordance with its instructions. Submission of this
statement is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required
statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

PRINTED NAME and TITLE

APPLICANT ORGANIZATION

DATE SIGNED

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Table 1:  Section 7002‐Eligible Federal Property in the Local Educational Agency
Applicant Name: 
Impact Aid Number:

School Year:

Instructions:  List all Section 7002‐eligible Federal property in the LEA.  When the eligible federal property is located in more than one 
jurisdiction, enter the total number of acres in each jurisdiction. In column 1, enter the name of the Section 7002‐eligible Federal property.  In 
column 2, enter the name of the corresponding taxing jurisdiction. In column 3, enter the number of acres associated with and approved as 
eligible federal acres for the purposes of the Impact Aid Program.  

Column 1
Name of Section 7002‐Eligible Federal Property (Generally, 
real property to which the Federal Government acquired 
ownership on or after 1939)

Column 2

Column 3

Taxing Jurisdiction

Number of Section 7002‐
eligible Acres

TOTAL NUMBER OF SECTION 7002‐ELIGIBLE FEDERAL ACRES:
If federal Impact Aid Program Section 7002‐eligible acres total has changed from last year's submission, provide an explanation 
and attach/upload official documentation for the change.  

Table 2:  Revenue from Eligible Federal Property
Applicant Name: 

Impact Aid Number:

School Year:

Instructions:  List all revenue from Federal and non‐Federal sources during the second preceding fiscal year (e.g., 2015‐2016 for the FY 2018 application) from activities 
associated with section 7002‐eligible Federal property.  If revenue is from Federal programs, provide the name of each Federal program and the name of the Federal agency 
responsible for administering that program.  If only a portion of the Federal property generating the revenue is eligible under section 7002, prorate the revenue to reflect 
the share attributable to the section 7002‐elgible property.  For example, if the LEA has 10,000 acres of U.S. Forest Service property that generated $20,000 in timber 
revenues, but only 2,000 acres are eligible under section 7002, the LEA should report one‐fifth (20 percent) of the total, or $4,000, as revenue associated with section 7002‐
eligble Federal property.  Do not report Impact Aid revenue or receipts from other U.S. Department of Education programs on this table. 

Column 1

Column 2

Source of Revenue (If Federal, also List Federal Agency and Program)

Funds Received During Fiscal Year (2011‐2012)

TOTALS:

Table 3:  Total Acreage and Taxable Value in the Local Educational Agency
Applicant Name: 
Impact Aid Number:

School Year:

Instructions:  Enter the total acreage located in the local educational agency (LEA) and the total taxable value for the purpose of levying property tax for school 
purposes for current expenditures of real property located within the boundaries of the local educational agency (LEA).  In column 1, enter the name of the taxing 
jurisdiction.  This information must match the jurisdictions listed on Table 1.  In column 2, enter the total acres located in the LEA boundaries or taxing jurisdiction 
(including the Section 7002‐eligible acres and other non‐taxable acres).  In column 3, enter the total taxable value, for the purposes of levying property tax for 
school purposes for current expenditures, of the acres listed in column 2, for the prior fiscal year (e.g., use fiscal year 2016‐2017 for the FY 2018 application or the 
specific taxable value as of January 2017).  If the LEA is located in more than one taxing jurisdiction (e.g., two counties) or contains more than one taxing jurisdiction 
(e.g., two townships), enter the information for each jurisdiction separately.  

Column 1

Column 2

Name of Taxing Jurisdiction (e.g.,  township name, 
city name, county name, etc.)

Total Acres located in LEA 
boundaries (or taxing 
jurisdiction) 

TOTALS:

Column 3
Total Taxable Value of Real Property in the LEA

Attachment:  You must upload documentation showing where the data was obtained.  The two options are:  
     1.  Attach the source of the official data, such as a document from your State's website, or website link.
     2.  If the documentation was obtained directly from a local official (e.g., local tax assessor for the data on taxable value), you must submit a 
certification by that official that includes the person's name, title, email address, and telephone number.

Table 4:  Tax Levy Information
Applicant Name: 

Impact Aid Number:

School Year:

Instructions: Enter the local real property tax levy, in mills or dollars, that was used to raise funds for current operating expenditures for the local educational agency (LEA) 
for the prior fiscal year (e.g., FY 2016‐2017 data for the FY 2018 application).  Enter a single tax rate for school operations expenditures for all types of real property in the 
jurisdiction. When funds for current operating expenditures for the LEA are raised by more than one taxing jurisdiction, enter the tax rate information for each additional 
jurisdiction on a separate line.

Column 1

Column 2

Name of taxing jurisdiction (e.g., school district name, township name, city name,  Tax Rate for Current Operating Expenditures for 
county name, etc.) Use separate line for each different taxable jurisdiction in the  This LEA for Fiscal Year 2016‐2017 (e.g., 2.5 mills 
LEA.
per $1.00 or $2.50 per $1,000)