Form Section 8003 Section 8003 Impact Aid Section 8003 Application

Final Filing Date:

01/31/2017

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) :

2018
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

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.
13.
14.
15.
16.
17.
18.

Has the legal authority to apply for Federal assistance and the institutional, managerial and financial capability (including funds sufficient to pay the nonFederal 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. 88352) 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 VIII 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.
1

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 VIII of
the ESEA), the program regulations (34 CFR Part 222), and program administrative requirements;
3. 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);
4. 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);
5. Any LEA claiming children residing on Indian lands will provide written responses to comments, concerns and recommendations received from tribal
leaders and parents of Indian children through the Indian policies and procedures consultation process and will disseminate these responses to tribal
leaders and parents of Indian children prior to the submission of their Impact Aid application; and
6. 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.

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
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

U.S. Department of Education
IMPACT AID PROGRAM
TAX EFFORT INFORMATION SHEET

LEA NAME:
APPLICATION# :

LEA’S DATA
STATE DATA
________________________________________________________________________
Tax rate(s) in mills used to raise funds for
raise use in SY:
(For School Purposes)

MILLS

Current Expense
Debt Service
Capital Outlay
Other
(Specify)______________
TOTAL:

Average tax rate(s) in mills used to
funds for use in SY:
(For School Purposes)

MILLS

Current Expense
Debt Service
Capital Outlay
Other
(Specify)____________
TOTAL:

LEA ADA DATA for SY:

CERTIFIED:
________________________________
Print Name and Title

___________________________
Signature

________________________________
Telephone number

___________________________
Email Address

_______
Date

HOUSING UNDERGOING RENOVATION OR REBUILDING – HOUSING OFFICIAL CONTACT INFORMATION 

1. 

Housing Official Name 

2. 
3. 

Housing Official Title 

Military Installation or Indian Lands 
Housing Area 

4. 

Housing Official Email Address 

5. 

Housing Official Phone Number 

6. 
Housing Official Phone Number 

This is an optional table that may be submitted by applicant LEAs where housing on a military 
installation or on Indian lands is temporarily unavailable for occupancy because it is undergoing 
renovation or rebuilding.  The Impact Aid Program uses this information 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.  The effect of 
categorizing these students in this way will be to increase the LEA’s maximum basic support payment.   
Due to a change in the Impact Aid statute, Tables 9 & 11 have been removed from the application and 
replaced by a single form for FY 2015 and subsequent applications.  If you are providing information for 
more than one military installation, provide a separate form for each.   

To upload the form, you will see an application form labeled “Housing Undergoing Renovation or 
Rebuilding” where you will upload the document “HOUSING UNDERGOING RENOVATION OR 
REBUILDING – HOUSING OFFICIAL CONTACT INFORMATION” for your housing official(s).  You will find 
this form on the right hand side of the screen, under the application instructions.  To be considered 
under this provision, you must complete this form and upload it on this table.