Application By Parent Or Guardian For Temp Emergency Impact Aid Displaced By Hurricanes And California Wildfires Attending A Non

ELEMENTARY AND SECONDARY EDUCATION 2018 Application By Parent Or Guardian For TEMPORARY Emergency Impact Aid On Behalf Of Students Displaced By Hurricanes Harvey, Irma, and Maria, or the 2017 cALIFORNIA wildfires And Who Are Attending A Non-public School
NAME OF PARENT OR GUARDIAN : STREET/P.O. BOX : CITY : COUNTY : STATE & ZIP : PHONE : EMAIL :
NAME OF NON‑PUBLIC SCHOOL : STREET/P.O. BOX : CITY : COUNTY : STATE & ZIP :
Names of children enrolled in this non‑public school prior to 2/9/2018:
Name of the local educational agency (local school district) within whose boundaries this non‑public school is located:
I request that the local educational agency named above make payments to Emergency Impact Aid Accounts on behalf of each of my children named above. I certify that I enrolled my children named above in this non-public school prior to February 9, 2018 (the date of enactment of the law authorizing Emergency Impact Aid for Displaced Students). I certify that my children named above, to the best of my knowledge and belief, were enrolled or were eligible to be enrolled in a school in an area for which the Federal Government later declared a major disaster or emergency related to Hurricanes Harvey, Irma, and Maria, or 2017 California wildfires and, as a result, are displaced students.
NAME OF PARENT	SIGNATURE	DATE

Appendix: Definition of Displaced Student

Displaced student

The term "displaced student'' means a student who enrolled in an elementary school or secondary school (other than the school that the student was enrolled in, or was eligible to be enrolled in, on the date that is one week prior to the date that the major disaster or emergency was declared for the area) because such student resides or resided on the date that is one week prior to the date that the major disaster or emergency was declared for the area, in an area for which a major disaster or emergency declared by the President in accordance with section 401 or 501, respectively, of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C. 5170), related to a covered disaster or emergency.

Section 107(b)(1) of Title IV of Division B of Public Law 109-148, as modified by Division B, Subdivision 1, Title VIII of P.L. 115-123, the “Bipartisan Budget Act of 2018.”

Form Approved:

– OMB number XXXX-XXX

– Expiration date: xxxxxxx