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FY 2009

APPLICATION FOR DEPARTMENT OF DEFENSE IMPACT AID FOR CHILDREN WITH SEVERE DISABILITIES FOR SCHOOL YEAR 2007-2008

OMB No. 0704-0425 OMB approval expires Nov 30, 2009

The public reporting burden for this collection of information is estimated to average 8 hours per response, including the 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 this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon, Washington, DC 20301-1155 (0704-0425). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

E-MAIL THIS APPLICATION TO: [email protected] FAX THE SIGNATURE SHEET ONLY TO: Office of the Under Secretary of Defense (Personnel and Readiness) Attn: Impact Aid (703) 588-5330

SECTION I - APPLICANT INFORMATION AND CERTIFICATION
DEFINITION OF SEVERE DISABILITY Children with severe disabilities means children with disabilities who because of the intensity of their physical, mental, or emotional problems need highly specialized education, social, psychological, and medical services in order to maximize their full potential for useful and meaningful participation in society and for self-fulfillment. The term includes those children with disabilities with severe emotional disturbance (including schizophrenia), autism, severe and profound mental retardation, and those who have two or more serious disabilities such as deaf-blindness, mental retardation and blindness, and cerebral palsy and blindness. ELIGIBILITY CRITERIA Under 20 U.S.C. 7703a, the local education agency (LEA) is eligible to receive a payment for a child described in subparagraph (A)(ii), (B), (D)(i) or (D)(ii) of section 8003(a)(1) of the Elementary and Secondary Education Act (ESEA) of 1965, as amended (20 U. S.C. 7703(a)(1)) if the LEA serves two or more such children with severe disabilities, for costs incurred in providing a free and appropriate education (FAPE) to each such child, where payment to be made only on behalf of children whose individual educational or related services cost exceeds either (a) five times the national or State average per pupil expenditure (whichever is lower) for a special education (SPED) program that is located outside the boundaries of the school district of the LEA that pays for the FAPE of the student, or (b) three times the State average per pupil expenditure for a SPED program offered by the LEA, or within the boundaries of the school district served by the LEA.
1.a. NAME OF LOCAL EDUCATION AGENCY (LEA) b. ADDRESS (Include ZIP Code)

2. Enter the national or State average per pupil expenditure (whichever is lower) used 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. 3. Enter the State average per pupil expenditure used 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. 4. Enter the total number of military dependent children in your district, for whom you are applying for a payment in this application, who meet the given definition of severe disability and whose cost for their educational and related services meets the eligibility criteria above. a. Of the total number of military dependent children listed in 4 above, enter the number of children that were residing in base housing or in military installation housing undergoing renovation or rebuilding, and are deemed as eligible for on base housing. b. Of the total number of military dependent children listed in 4 above, enter the number of children that were residing in off base housing. 5. PERSON COMPLETING THIS APPLICATION a. NAME (Last, First, Middle Initial) c. TELEPHONE NUMBER (Include Area Code) 6. CERTIFICATION d. E-MAIL ADDRESS

b. TITLE

I certify that I have read the information contained in this application and have found that all of the data included in this application is, to the best of my knowledge and belief, true, complete, and accurate. I certify that I am authorized to make the representations and commitments in this applicaton, for and on behalf of the applicant and otherwise act as the applicant's authorized representative in submitting this application for funding under section 363 of P.L. 106-398 (National Defense Authorization Act for Fiscal Year 2001), as amended.
a. NAME OF CERTIFYING OFFICIAL (Last, First, Middle Initial) b. SIGNATURE

c. E-MAIL ADDRESS

d. DATE SIGNED (YYYYMMDD) PREVIOUS EDITION IS OBSOLETE. Page 1 of 3 Pages
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SD FORM 816, MAR 2009

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FY 2009

APPLICATION FOR DEPARTMENT OF DEFENSE IMPACT AID FOR CHILDREN WITH SEVERE DISABILITIES FOR SCHOOL YEAR 2007-2008

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

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.

SD FORM 816, MAR 2009

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FY 2009

APPLICATION FOR DEPARTMENT OF DEFENSE IMPACT AID FOR CHILDREN WITH SEVERE DISABILITIES FOR SCHOOL YEAR 2007-2008

SECTION III - FINANCIAL ORGANIZATION DIRECT DEPOSIT INFORMATION
If your LEA is eligible to receive payment under the Impact Aid for Children with Severe Disabilities Program, please submit the following information on your financial organization. INCOMPLETE OR INACCURATE INFORMATION WILL DELAY PROCESSING AND PAYMENT.
1. NAME OF LOCAL EDUCATIONAL AGENCY (LEA)

2. NAME OF FINANCIAL ORGANIZATION

3. ADDRESS OF FINANCIAL ORGANIZATION (Include ZIP Code)

4. ROUTING TRANSIT NUMBER

5. YOUR AGENCY'S ACCOUNT NUMBER

6. FEDERAL TAX IDENTIFICATION NUMBER (Required by our disbursing agent)

7. NAME OF PERSON TO CONTACT (Last, First, Middle Initial)

8. TITLE OF PERSON TO CONTACT

9. TELEPHONE NUMBER (Include Area Code)

PLEASE E-MAIL THIS APPLICATION TO: [email protected] FAX THE SIGNATURE SHEET ONLY TO: Office of the Under Secretary of Defense (Personnel and Readiness) Attn: Impact Aid (703) 588-5330 SD FORM 816, MAR 2009
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Page 3 of 3 Pages

FY 2009

APPLICATION FOR DEPARTMENT OF DEFENSE IMPACT AID FOR CHILDREN WITH SEVERE DISABILITIES FOR SCHOOL YEAR 2007-2008

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:

2

X

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.

$65,000

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.

$1,480

SD FORM 816, MAR 2009

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