SD 816 Application for Department of Defense Impact Aid for Chi

APPLICATION FOR DEPARTMENT OF DEFENSE
IMPACT AID FOR CHILDREN WITH SEVERE DISABILITIES
FOR SCHOOL YEAR 20 - 20

FY 20

OMB No. 0704-0425
OMB approval expires
mm/dd/yyyy

The public reporting burden for this collection of information, 0704-0425, 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 the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at
whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. 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.

PLEASE DO NOT RETURN YOUR RESPONSE TO THE ABOVE ADDRESS.
Applications should be emailed to DoDEAimpactaid@dodea.edu

SECTION I - APPLICANT INFORMATION AND CERTIFICATION
DEFINITION OF SEVERELY DISABLED
A student whose disabilities involve extensive mental, physical and/or behavioral impairment, or a combination of multiple
impairments, likely to be permanent in nature and greatly compromising an individual's ability to function independently in the
community, perform self-care, and obtain employment, in accordance with State rules implementing the Individuals with Disabilities
Education Act, as amended, 20 U.S.C. 1400 et seq., and for whom the local educational agency (LEA) is providing more special
education and related services than are provided for children with mild and moderate disabilities in special education programs.
ELIGIBILITY CRITERIA
An LEA is eligible for financial assistance for severely disabled military dependent students under 20 U.S.C. 7703a, if 1) the LEA
provides a free and appropriate education (FAPE) to two or more such children with severe disabilities, and 2) if the LEA incurs
individual costs for providing FAPE that exceed (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 EDUCATIONAL 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 minimum of two students must be claimed for eligibility purposes.
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)

b. TITLE
d. E-MAIL ADDRESS

6. CERTIFICATION

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 application, 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

SD FORM 816, MONTH YEAR

d. DATE SIGNED (YYYYMMDD)
PREVIOUS EDITIONS ARE OBSOLETE.

Page 1 of 3 Pages

FY 20

APPLICATION FOR DEPARTMENT OF DEFENSE
IMPACT AID FOR CHILDREN WITH SEVERE DISABILITIES
FOR SCHOOL YEAR 20 - 20

SECTION II - PAYMENT DETERMINATION
INSTRUCTIONS
In order to determine the amount the LEA is eligible to receive for each military dependent child with a severe
disability, complete a page 2 (this page) to compute special education and related service costs for each child for
the applicable school year.

1. Enter the number of children with special needs in box 1.
If the costs are the same for two or more children, enter the number of children with that
same set costs in box 1.These children must meet the definition of severe disability as
stated on page 1.

Check box 1.a. or 1.b. below

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. Enter the total cost associated with the special education and related services of the
military dependent child with severe disabilities. This is the cost for all services provided
to a single child with a severe disability that meets the criteria of 1.a. or 1.b. above. If
more than one child is listed in box 1 above, only list the cost associated with 1 of the
children here.

3. Enter the amount received from sources other than the State, the Individuals with
Disabilities Act, or Federal Impact Aid. This would include funding that was provided to
defray the cost of educational and related services to the child which are received due to
the presence of a severe disabling condition. An example would be any funds received by
Medicaid. If more than one child is listed in box 1 above, only list the cost associated with
1 of the children here.
SD FORM 816, MONTH YEAR

Page 2 of 3 Pages

APPLICATION FOR DEPARTMENT OF DEFENSE
IMPACT AID FOR CHILDREN WITH SEVERE DISABILITIES
FOR SCHOOL YEAR 20 - 20

FY 20

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. DUNS and banking information must be current on www.sam.gov.
INCOMPLETE OR INACCURATE INFORMATION WILL DELAY PROCESSING AND PAYMENT.
1. NAME OF LOCAL EDUCATIONAL AGENCY (LEA)

2. ACTIVE DUNS NUMBER (www.sam.gov)

3. NAME OF FINANCIAL ORGANIZATION

4. ADDRESS OF FINANCIAL ORGANIZATION (Include ZIP Code)

5. ROUTING TRANSIT NUMBER

6. YOUR AGENCY'S ACCOUNT NUMBER

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

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

9. TITLE OF PERSON TO CONTACT

10. TELEPHONE NUMBER (Include Area Code)

PLEASE E-MAIL THIS APPLICATION TO:
DoDEAimpactaid@dodea.edu

SD FORM 816, MONTH YEAR

Page 3 of 3 Pages

FY 20

APPLICATION FOR DEPARTMENT OF DEFENSE
IMPACT AID FOR CHILDREN WITH SEVERE DISABILITIES
FOR SCHOOL YEAR 20 - 20

SECTION II - PAYMENT DETERMINATION
INSTRUCTIONS
In order to determine the amount the LEA is eligible to receive for each military dependent child with a
severe disability, complete a page 2 (this page) to compute special education and related service costs for
each child for the applicable school year.

Example
of
Page 2

1. Enter the number of children with special needs in box 1.

If the costs are the same for two or more children, enter the number of children with that
same set costs in box 1.These children must meet the definition of severe disability as
stated on page 1.

Check box 1.a. or 1.b. below

X

2

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. Enter the total cost associated with the special education and related services of the
military dependent child with severe disabilities. This is the cost for all services provided to a
single child with a severe disability that meets the criteria of 1.a. or 1.b. above. If more than
one child is listed in box 1 above, only list the cost associated with 1 of the children here.

$65,000

3. Enter the amount received from sources other than the State, the Individuals with
Disabilities Act, or Federal Impact Aid. This would include funding that was provided to
defray the cost of educational and related services to the child which are received due to
the presence of a severe disabling condition. An example would be any funds received by
Medicaid. If more than one child is listed in box 1 above, only list the cost associated with 1
of the children here.

$1,480

SD FORM 816, MONTH YEAR

Example Page