STUDENT INFORMATION

Student Name: ________________________________________________________________________ MCPS Student ID:_______________

Address: _________________________________________________________________________________ Student DOB: ____/____/_____

School Name: _____________________________________________________________________________________________ Grade: ____

If the above property is a military or federal housing project? o Yes o No If YES, enter the name of the property _________________

PARENT/GUARDIAN INFORMATION

1. UNIFORMED SERVICES

Was either parent/guardian on active duty in the Uniformed Services on October 6, 2021?

o YES, complete information in this section, sign and date.

o NO, go to Section 2.

UNITED STATES MILITARY

Parent/Guardian Name (Last, First, MI) _______________________________________________________________

Military Rank/Grade ________________________________________________________________________________

Branch of Service: o Air Force o Army o Coast Guard o Marine Corps o Navy o NOAA Corps o USPHS o National Guard or Reserves, please attach a copy of Title 10 USC activation orders

FOREIGN MILITARY OFFICER

Enter information in this section regarding the parent/guardian if either person is a foreign military officer on the survey date.

Parent/Guardian Name (Last, First, MI) _______________________________________________________________

Military Rank/Grade ___________________________ Foreign Government Name_____________________________

Branch of Service: o Air Force o Army o Marine Corps o Navy

2. WORKS ON FEDERAL PROPERTY (Civilian)

Was either parent/guardian with whom the student resided employed on federal property in Maryland on October 6, 2021? This includes employees working remotely.

o YES, complete information in this section, sign and date.

o NO, sign and date.

FEDERAL PROPERTY

Parent/Guardian Name (Last, First, MI) _______________________________________________________________

Employer’s Address of Parent/Guardian __________________________________________________________________________

Check Federal Property Below:

o Andrews AFB—5550 Dower House Rd, Upper Marlboro, MD 20772o Army Research Lab— 2800 Powder Mill Rd, Adelphi, MD 20783o Centers for Medicare & Medicaid Svcs—7500 Security Blvd,

Baltimore, MD 21244o Dept of Energy—19901 Germantown Rd, Germantown, MD 20874o DoD Unif Serv University of Health—4301 Jones Bridge Rd,

Bethesda, MD 20814o Food & Drug Admin—10903 New Hampshire Ave, Silver Spring,

MD 20993o Food & Drug Admin—5001 Campus Drive, College Park, MD 20740o Fort Detrick—Frederick, MD 21702o Fort Meade—Fort Meade, MD 20755o ICC-B—4600 Sangamore Rd, Bethesda, MD 20816o Internal Revenue Service—5000 Elin Rd, Lanham, MD 20706o Joint Base Andrews—1500 W. Perimeter Rd, Andrews AFB, MD 20762o NASA—8800 Greenbelt Rd, Greenbelt, MD 20771o Nat’l Archives at College Park—8601 Adelphi Rd, College Park, MD

20740o Nat’l Institute of Standards & Tech—100 Bureau Dr, Gaithersburg,

MD 20899o Nat’l Institutes of Health—9000 Wisconsin Ave/

Rockville Pk, Bethesda, MD 20892

o Nat’l Library of Med—8600 Wisconsin Ave/Rockville Pk, Bethesda, MD 20894

o Naval Medical Research Ctr—503 Robert Grant Ave, Silver Spring, MD 20910

o Naval Surface Warfare Ctr—9500 MacArthur Blvd, Bethesda, MD 20817

o NOAA—1335 East West Highway, Silver Spring, MD 20910o Nuclear Reg Commission—11555 Rockville Pk, Rockville, MD 20852o Social Security Admin—6401 Security Blvd, Baltimore, MD 21235o Walter Reed Nat’l Mil Med Ctr—8901 Wisconsin Ave, Bethesda,

MD 20889o US Census Bureau—4600 Silver Hill Rd, Suitland, MD 20746o US Dept of Agriculture— 10300 Baltimore Ave, Beltsville, MD 20705

5601 Sunnyside Ave., Beltsville, MD 20740 4700 River Road, Riverdale, MD 20737

o US Naval Academy—121 Blake Rd, Annapolis, MD 21420

o Other Federal Property (please specify): _____________________

Address ______________________________________________

_____________________________________________________

This information is the basis for payment to MCPS of federal funds under the Impact Aid Program (Title VII of the Elementary and Secondary Act) and may be provided to the U.S. Department of Education if your school district’s application for payment is audited. This form must be signed and dated for MCPS to receive funds based on this information.

By signing this form I am certifying that all typed and written information on this form is accurate and complete as of the survey date.

Signature of Parent/Guardian ____________________________________________________________________________________Date _____/_____/______

Return Information: The completed survey can be returned to student’s school; by fax to 301-279-3031; emailed to impactaid@mcpsmd.org; or mailed to MCPS Division of Controller, 45 W. Gude Drive, Suite 3201, Rockville, MD 20850

Federal Impact Aid SurveyA S O F O C T O B E R 6 , 2 0 2 1

Division of ControllerMONTGOMERY COUNTY PUBLIC SCHOOLS

45 W. Gude Drive, Rockville, Maryland 20850 301-279-3039

MCPS Form 280-4October 2021

November 1, 2021

Dear Parent or Guardian:

Each year, Montgomery County Public Schools (MCPS) is eligible to apply for the Federal Impact Aid grant funds. Impact Aid is a federal formula grant program designed to assist local school districts that enroll federally-connected students. Federally-connected students are defined as children of active duty uniformed services personnel, children who live on federal property or federally subsidized housing units, and children whose parents are employed on eligible federal properties in Maryland. This would include contractors working on federal reservations and Non-Appropriated Fund (NAF) employees.

The funds MCPS collects are vital part of the school system’s general operating budget and are critical to helping all students. This year we are working with our local federal partners and we need your assistance to identify students with federal, military and diplomatic connections to ensure MCPS is able to obtain its share from this program. If you believe your child qualifies as federally-connected, please complete the Student-Parent Survey for Federal Impact Aid form on the reverse of this letter for each school-aged stu-dent in your household. Please sign and date the form, returning the survey to your child’s school folded in half and stapled once or taped, no later than Friday, December 10, 2021. All information provided will be treated confidentially.

Information on the Federal Impact Aid Program and the Student-Parent is available at the below link.

https://www.montgomeryschoolsmd.org/departments/forms/detail.aspx?formID=103&formNumber=280-4&catID=2&subCatId=0.

Thank you for your time and consideration on this issue.

Sincerely,

Monifa B. McKnight, Ed.D.Interim Superintendent of Schools

MBM:ESD:RR

Copy to: Impact Aid file

OFFICE OF THE SUPERINTENDENT OF SCHOOLS

850 Hungerford Drive Room 122 Rockville, Maryland 20850 240-740-3020 montgomeryschoolsmd.org