Application By Local Educational Agencies For Temporary Emergency Impact Aid For Displaced Students

ELEMENTARY AND SECONDARY EDUCATION 2018 APPLICATION BY LOCAL EDUCATIONAL AGENCIES FOR TEMPORARY EMERGENCY IMPACT AID FOR DISPLACED STUDENTS
LEA NAME : STREET/P.O. BOX : CITY : COUNTY : STATE & ZIP :
CONTACT PERSON NAME : TITLE : PHONE : FAX : E-MAIL :
I certify that the school district has contacted all non-public schools within the district’s boundaries to notify them of the availability of funding under this program and that the district has reviewed documentation to verify the eligibility of any non-public school students included in counts in this application as meeting the definition of displaced students, as defined in 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.” I certify that the school district will make payments to Individual Emergency Impact Aid Accounts for students enrolled in non‑public schools who are counted on this application within 14 calendar days of the school district’s receipt of funds provided for this application. I certify that public school student counts included in this application meet the definition of displaced students. I certify that the 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.
NAME AND TITLE OF AUTHORIZED REPRESENTATIVE	SIGNATURE	DATE

State __________________________	2018 APPLICATION BY LOCAL EDUCATIONAL AGENCIES FOR EMERGENCY IMPACT AID FOR DISPLACED STUDENTS QUARTERLY NUMBERS OF DISPLACED STUDENTS
LEA NAME :
Report total numbers of displaced students in the school district by category for each applicable quarter. Use whole numbers only. Do not include any students in more than one category in a single quarter. For each quarter, report the number of displaced students as of the reporting date for that quarter. (LEAs must submit enrollment data for all four quarters of the 2017-18 school year, which may include estimated data for the fourth quarter. LEAs must provide as an update to this application any updated enrollment data generally and any unreported fourth quarter data for the 2017-18 school year once that data becomes available but no later than the deadline set by the SEA.)
	Quarter 1 on __________, 2017	Quarter 2 on __________, 2017	Quarter 3 on __________, 2018	Quarter 4 on __________, 2018
PUBLIC SCHOOLS: Total number of displaced students: enrolled in the elementary and secondary schools (including charter schools) of the school district, and who are not receiving special education and related services consistent with IDEA who are not English learners
PUBLIC SCHOOLS: Total number of displaced students: enrolled in the elementary and secondary schools (including charter schools) of the school district, and who are receiving special education and related services consistent with IDEA
PUBLIC SCHOOLS: Total number of displaced students: enrolled in the elementary and secondary schools (including charter schools) of the school district, who are not receiving special education and related services consistent with IDEA, and who are English learners

State __________________________	2018 APPLICATION BY LOCAL EDUCATIONAL AGENCIES FOR EMERGENCY IMPACT AID FOR DISPLACED STUDENTS QUARTERLY NUMBERS OF DISPLACED STUDENTS
LEA NAME :
Report total numbers of displaced students in the school district by category for each applicable quarter. Use whole numbers only. Do not include any students in more than one category in a single quarter. For each quarter, report the number of displaced students as of the reporting date for that quarter. (LEAs must submit enrollment data for all four quarters of the 2017-18 school year, which may include estimated data for the fourth quarter. LEAs must provide as an update to this application any updated enrollment data generally and any unreported fourth quarter data for the 2017-18 school year once that data becomes available but no later than the deadline set by the SEA.)
	Quarter 1 on ______, 2017	Quarter 2 on ______, 2017	Quarter 3 on ______, 2018	Quarter 4 on ______, 2018
NON‑PUBLIC SCHOOLS: Total number of displaced students: for whom the school district expects to provide payments to Individual Emergency Impact Aid Accounts, and who are not receiving special education and related services consistent with IDEA who are not English learners
NON‑PUBLIC SCHOOLS: Total number of displaced students: for whom the school district expects to provide payments to Individual Emergency Impact Aid Accounts, and who are receiving special education and related services consistent with IDEA
NON‑PUBLIC SCHOOLS: Total number of displaced students: for whom the school district expects to provide payments to Individual Emergency Impact Aid Accounts, who are not receiving special education and related services consistent with IDEA, and who are English learners

Additional Requirements for LEAs

In addition to the information provided above, LEAs must ensure to comply with:

• the procedures, as established by the SEA, that the LEA will use to receive applications for assistance from the parents or guardians of non-public school students;

• the procedures, as established by the SEA, that the LEA will use to make payments to accounts for non-public school students;

• the procedures, as established by the SEA, that the LEA will use to obtain:

  • Certifications of attendance from non-public schools for displaced students; and

  • Certifications from non-public schools that payments for displaced non-public school students will be used only for allowable purposes.

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:

PAGE: 4 – OMB number 1810-XXXX

– Expiration date: xx