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Final Filing Date: 01/31/2006 U.S.

Department of Education Form Approved:


Impact Aid Program --OMB number 1810-0036
Washington, D.C. 20202-6244 --Expiration date: 06/30/2008
Applicants must submit complete
APPLICATION FOR IMPACT AID - SECTION 8002
2007
applications (ED Form 4019) on or
before this filing deadline to receive
full payments. See the instructions
for further information. 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.

ORIGINAL APPLICATION: DUNS NUMBER PR/AWARD NUMBER IMPACT AID NUMBER

AMENDMENT:

APPLICANT NAME : CONTACT PERSON NAME :


STREET/P.O. BOX : TITLE :
CITY : PHONE :
COUNTY : FAX :
STATE & ZIP : E-MAIL:

CHECK IF THE NUMBER OF ACRES OF ANY ELIGIBLE 8002 PROPERTY HAVE CHANGED SINCE THE LAST FILING FOR IMPACT AID FUNDING. *

CHECK IF THE APPLICANT'S BOUNDARIES HAVE CHANGED SINCE THE LAST FILING FOR IMPACT AID FUNDING. *
* If you check either of these boxes, the Impact Aid Program will contact you to request additional information.

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 8002 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 DATE

ED 4019 Revised 05/31/2005 PAGE: 1


APPLICATION FOR IMPACT AID - SECTION 8002

IMPACT AID PROGRAM ASSURANCES AND CERTIFICATIONS


The applicant hereby declares that it has filed the following assurances and certifications covering the Impact Aid Program with the U.S. Department of Education,
and, as of the date of the signature below, reaffirms and incorporates by reference those assurances and certifications in this Impact Aid application.* The applicant
certifies that no circumstances affecting the validity of the following assurances have changed since their previous filing:

• As applicable, the assurances in OMB Standard Form 424B (Assurances for Non-Construction Programs), relating to legal authority to apply for assistance;
access to records; conflict of interest; merit systems; nondiscrimination; Hatch Act provisions; labor standards; flood insurance; environmental standards; wild
and scenic river systems; historic preservation; protection of human subjects; animal welfare; lead-based paint; Single Audit Act; and general agreement to
comply with all Federal laws, executive orders and regulations;

• The certification regarding lobbying in ED Form 80-0013; and

• With respect to the Certification Regarding Lobbying, the LEA recertifies that no Federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of Congress, or an employee of a Member of Congress, in connection with the making or renewal
of Federal grants under this program; that the LEA will complete and submit Standard Form LLL "Disclosure Form to Report Lobbying," when required (34 CFR
Part 82, Appendix B); and that the LEA will require the full certification, as set forth in 34 CFR Part 82, Appendix A, in the award documents for all subawards at
all tiers.

The applicant further assures that:

• 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;

• 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; and

• 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. 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.

*If the applicant is applying for Impact Aid assistance for the first time, the applicant also must file with the Impact Aid Program by the filing deadline the following
assurances and certification that it can obtain from the IAP: OMB Standard Form 424B (Assurances for Non-Construction Programs) and ED Form 80-0013
(certification regarding lobbying).

SIGNATURE: DATE:
ED 4019 Revised 05/31/2005 PAGE: 2 Form Approved:
--OMB number 1810-0036
--Expiration date: 06/30/2008
APPLICATION FOR IMPACT AID SECTION 8002 - TABLE 1

TABLE 1. TAX ASSESSOR'S VALUATION OF SECTION 8002-ELIGIBLE FEDERAL PROPERTY


See the instructions before completing this table. When eligible Federal property is located in more than one taxing jurisdiction, submit separate copies of this table for each
jurisdiction. The official signing this document must retain records documenting the method used to determine the value of the Federal property for at least three years after
the last payment for a fiscal year. These records must include identification of the taxable adjacent properties used as the basis for the valuation and their assessed values
used for taxation purposes for the tax year in question (34 CFR 222.10 and 222.23).

(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6) (Col. 7)


Name of Section 8002-Eligible Number of Types and Proportions of Average Fair Market Adjustment Factor Average Assessed Estimated Assessed Value
Federal Property Eligible Acres Taxable Property Value Per Acre for Used to Convert Value Per Acre for for Portion of Federal
(Generally, real property to which the Adjacent to Federal This Type of Property Market Value to This Type of Property Based on This Type
Federal Government acquired Property Assessed Value Property of Adjacent Property
ownership on or after 1939)
(Col. 4 x Col. 5) (Col. 2 x Col. 3 x Col. 6)
Example: Example: Example: Example: Example: Example: Example:
National Grasslands 34,000 Agricultural 96% $570.75 92% $525.09 $17,138,937.60
Residential 1% $46,227.50 100% $46,227.50 $15,717,350.00
Commercial 3% $19,521.35 92% $17,959.64 $18,318,832.80

TOTAL FOR COLUMN 7


(If this figure has changed by 20 percent or more from last year's submission, attach an explanation for the change.) $
Certification by Tax Assessment Official: I hereby certify that the
Name of Jurisdiction (e.g. county name)
above information is accurate and complete to the best of my knowledge.
Name of Certifying Official
Title of Certifying Official
Telephone Number of Certifying Official
Signature Date
ED 4019 Revised 05/31/2005 PAGE: 3-1 Form Approved:
--OMB number 1810-0036
--Expiration date: 06/30/2008
APPLICATION FOR IMPACT AID SECTION 8002 - TABLE 2

TABLE 2. FEDERAL REVENUE FROM ELIGIBLE FEDERAL PROPERTY


Instructions: List all revenues received from other Federal programs during the previous fiscal year (2003-2004) from activities associated with section 8002-eligible Federal property.
Provide the name of each Federal program and the name of the Federal agency responsible for administering that program. If only a portion of the Federal property generating the
revenue is eligible under section 8002, prorate the revenue to reflect the share attributable to the section 8002-eligible property. For example, if the LEA has 10,000 acres of U.S.
Forest Service property that generated $20,000 in timber revenues, but only 2,000 acres are eligible under section 8002, the LEA should report one fifth (20 percent) of the total, or
$4,000, as revenue associated with section 8002-eligible Federal property.
(Col. 1) (Col. 2)
Federal Program and Federal Agency Funds Received During Fiscal Year
2003-2004

TOTAL $

ED 4019 Revised 05/31/2005 PAGE: 4-1 Form Approved:


--OMB number 1810-0036
--Expiration date: 06/30/2008
APPLICATION FOR IMPACT AID SECTION 8002 - TABLE 3

TABLE 3. ASSESSED VALUE OF TAXABLE REAL PROPERTY IN THE LOCAL EDUCATIONAL AGENCY
Instructions: List each type of taxable real property in the local educational agency (LEA) and report the number of acres and assessed value for tax purposes for
each. If the LEA is located in more than one taxing jurisdiction (e.g., two counties) or contains more than one taxing jurisdiction (e.g., two townships), list the
information for each jurisdiction separately. This page may be copied if more space is needed.

(Col. 1) (Col. 2) (Col. 3) (Col. 4)


Name of Taxing Jurisdiction Type of Taxable Property Total Acres Total Assessed Value
(e.g., school district name, township name, (e.g., residential, commercial, agricultural, etc.) of This Type of Property of This Type of Property
city name, county name, etc.)

ED 4019 Revised 05/31/2005 PAGE: 5-1 Form Approved:


--OMB number 1810-0036
--Expiration date: 06/30/2008
APPLICATION FOR IMPACT AID SECTION 8002 - TABLE 4

TABLE 4. TAX LEVY INFORMATION


Instructions: Enter the local real property tax levy, in mills or dollars, that was used to raise funds for current operating expenditures for the local
educational agency (LEA) for fiscal year 2004-2005. Exclude capital outlay, debt service or any other funds that are not considerred operating expenditures.
Tax assessors for school districts with a single tax rate will only need to use one line of this table. Local tax assessing officials for school districts
that have multiple tax rates should use a separate line to report each type of property and corresponding tax rate.

When funds for current operating expenditures for the LEA are raised by more than one taxing jurisdiction, submit separate copies of this table for each
jurisdiction.

(Col. 1) (Col. 2) (Col. 3)


Name of Taxing Jurisdiction Type of Taxable Property Tax Rate for
(e.g., school district name, township name, (e.g., residential, commercial, Current Operating Expenditures for
city name, county name, etc.) agricultural, etc.) This Type of Property for
Use a separate page for each different Fiscal Year 2004-2005
taxing jurisdiction in the LEA.

Example: Example: Example:


Jones County Residential, Commercial & Agricultural $1.50 per $100.00 of Assessed Value

per $

per $

per $

per $

per $

per $

per $

ED 4019 Revised 05/31/2005 PAGE: 6-1 Form Approved:


--OMB number 1810-0036
--Expiration date: 06/30/2008