SAMPLE TITLE VIII—IMPACT AID SAMPLE

Indian Lands Property Claimed on Table 1, 3 or 5 (non-Alaska applicants)

Fiscal Year ________ (School Year ________-________)

Applicant Name: Applicant Number: Survey Date:

Location of property claimed as Title VIII Indian lands on Children claimed on Table 1 or 3 as residing on
table 1, 3 or 5 of application. Indian lands or on Table 5 as residing with a
Indian lands Taxable parent employed on Indian lands.
status (yes or no)
Resided (trust or for leased,
Legal
on (R) restricted restricted
description
Name of or Table
Parent’s Specific street (e.g., section, property property Name of Date Grade
reservation or employed claimed on
name address township, only) only child of birth level
other locator on (E) (1, 3 or 5)
range, lot) or
the federal
tract number
property*
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)

* Enter R if parent in Column (2) resided on the property identified in Column (4) or (5);
enter E if parent in Column (2) was employed on the property identified in Column (4) or (5). (OVER)

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 SAMPLE TITLE VIII—IMPACT AID SAMPLE
Indian Lands Property Claimed on Table 1, 3 or 5 (non-Alaska applicants)
Fiscal Year ________ (School Year ________-________)

CERTIFICATION OF ELIGIBILITY OF INDIAN LANDS:

I hereby certify that each parcel indicated as being “trust” or "restricted” in Column (6) is either 1) owned by the United States and held in trust for an
individual Indian or Indian tribe or 2) held by an individual Indian or Indian tribe subject to restrictions on alienation imposed by the United States.

_________________________________ ____________________ ___________

Signature and Title, BIA Official Telephone Number Date

I hereby certify that each parcel of leased, restricted property listed in Column (7) as being not taxable is exempt from state and local real property
taxes for elementary and secondary school current expenditures purposes, and that this exemption is due to federal law, agreement or policy.

_________________________________ ____________________ ___________

Signature and Title, Tax Assessor Telephone Number Date
__________________________________________________________________________________________________________________________

CERTIFICATION OF PARENT/CHILD ELIGIBILITY:

I hereby certify that the information shown under Column (3) is correct for the person listed in Column (2) on the survey date.

_________________________________ ____________________ ___________

Signature and Title, Tribal Official Telephone Number Date

I hereby certify that the students listed in Column (8) were enrolled in this school system on the survey date.

_________________________________ ____________________ ___________

Signature and Title, School District Official Telephone Number Date

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