Sample impact Aid Program Source Check Form sample indian Lands Property Claimed on Tables 1, 3 or 5 (Except ansca and ok tribal Treaty Land Applicants) Application Fiscal Year: School Year: lea name: Survey Date: iap application Table



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SAMPLE Impact Aid Program Source Check Form SAMPLE

Indian Lands Property Claimed on Tables 1, 3 or 5 (Except ANSCA and OK Tribal Treaty Land Applicants)

Application Fiscal Year: _______________ School Year: ______________________

LEA Name: _____________________ Survey Date: _____________ IAP Application Table:______

( List only one table and one property per form)

Name of Indian Land Property Claimed_________________________________________________________________________

Complete Address/Property Description_________________________________________________________________

Applicant Number:_________________________________


Location of property claimed as Title VIII Indian lands on

Table 1, 3 or 5 of application.




Indian Lands status

(Trust, Restricted or Leased Restricted property only)



Taxable (yes or no)

for Leased Restricted property only **



Children claimed on Table 1 or 3 as residing on Indian Lands or on Table 5 as residing with a parent employed on Indian Lands.

Name of Reservation or other Locator

Parent’s Name

Resided

on (R)


or

employed


on (E)

the Federal

Property *


Parent/Guardian

Complete Address, City, State, Zip Code or

Legal description

(e.g., section, township, range, lot) or tract number




Name of Child

Date of Birth

Grade Level

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)





































































































































































































































































































































* Enter R if parent in Column 2 resided on the property identified in Column 4.

Enter E if parent in Column 2 was employed on the property identified in Column 4.

**Include in this column only property that is leased from another entity by an individual Indian or Indian tribe, and that is subject to restrictions on transfer (i.e., the Parcel

may not be transferred by the individual Indian tribe without the approval of a Federal agency).


SAMPLE Impact Aid Program Source Check Form SAMPLE

Indian Lands Property Claimed on Table 1, 3 or 5 (Except ANCSA and OK Tribal Treaty Land Applicants)

Application Fiscal Year: _______________ School Year: ______________________

LEA Name: _____________________ Survey Date: _____________ IAP Application Table______(List only one table and

property per form)

CERTIFICATION OF ELIGIBILITY OF INDIAN LANDS:

I hereby certify that on the survey date, each parcel of property (column 4) indicated as being “trust” or "restricted” in Column 5 is either (a) owned by

the United States and held in trust for an Individual Indian or Indian tribe or (b) held by an individual Indian or Indian tribe subject to restrictions on

alienation imposed by the United States.


_________________________________________ ___________________________ _________________ ___________

Print Name and Title, BIA/Tribal Official Signature, BIA/Tribal Official Telephone Number Date

I hereby certify that on the survey date, each parcel property (column 4) listed in column 5 as leased, restricted indicated in column 6 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.

_________________________________________ ___________________________ _________________ ___________

Print Name and Title, Tax Assessor Signature, Tax Assessor Telephone Number Date

__________________________________________________________________________________________________________________________


CERTIFICATION OF PARENT/CHILD ELIGIBILITY:


I hereby certify that the information shown under columns 1, 2, 3, and 7 is correct as of the survey date.


_________________________________________ ___________________________ _________________ ___________

Print Name and Title, Tribal Official/ Employer Signature, Tribal Official Telephone Number Date


I hereby certify that the students listed in column 7 were enrolled in this school district on the survey date, and the information listed in columns

8 and 9 is correct.


_________________________________________ ___________________________ _________________ ___________

Print Name and Title, School Official Signature, School Official Telephone Number Date

Indian Lands Source Check Form Instructions



(Except ANCSA and OK Tribal Treaty Land Applicants)
The Local Education Agency (LEA) may count the membership of its federally connected children who reside on trust or restricted land by using a source check form to substantiate the child’s place of residence on the survey date. The applicant can use the sample form attached or create one of its own that incorporates all required data elements. The LEA is responsible for ensuring completion and verification of all required data elements.

The certifying official (s) reviews the information provided and certifies that it is correct as of the survey date.




  • List only one Federal property per source check form.




  • All addresses on source check forms must be complete and include city, state, and zip code. If a street address is not available, the complete legal description may be provided.




Complete Street Address Example:

31842 Joe Creek Rd

Harold, SD 57536


Complete Legal Description Examples:

Lot 1, Block 2, Tract A

NE ¼, Section 12, T1N, T2W

Trust Indian Land Property is real property that is tax-exempt due to Federal law, agreement, or policy, and that is held in trust by the United States for individual Indians or Indian tribes.


Restricted Indian Land Property is real property that is tax-exempt due to Federal law, agreement, or policy, and that is held by individual Indians or Indian tribes subject to restrictions on alienation imposed by the United States.
Leased Restricted Indian Land Property is restricted Indian land property (as defined above) that is leased from another entity by an individual Indian or Indian tribe that is subject to restrictions on transfer (that is, the parcel may not be transferred by the individual Indian or Indian tribe without the approval of a Federal agency.)
The LEA provides the Indian Lands source check form to the following people:

  • Bureau of Indian Affairs (BIA)/Tribal official who certifies that each parcel indicated on the source check list is trust or restricted land.

  • A Tax assessor who verifies the tax exempt status of the Indian Land for Leased Restricted property.

  • A tribal official, who certifies that the parent or guardian of each pupil claimed resides on Indian lands over which that tribal official has jurisdiction, and that a parent is employed on Indian lands. The tribal official may need to consult with employers, and keep records provided by the employers to verify employment on Indian lands. The official may also need to consult with tribal housing officials to confirm residence, and should keep appropriate documentation on file.

  • An authorized school official, who certifies the name, Date of Birth (D.O.B.), grade level, and that the child was enrolled in the school system on the survey date.

Follow the instructions below to complete this form correctly.


Complete Top of Form
Application Fiscal Year: Enter the application fiscal year. This will be the same as the fiscal year on the application.
LEA Name: Enter the name of the school district on the top of the form.
School Year: Enter the current school year.
Survey Date: Enter the survey date at the top of the form.
Impact Aid Table: Enter the table property is claimed on
Address: Enter complete address of the Indian Land Property Claimed
Applicant Number: Enter the Impact Aid application number of the LEA
Complete Columns

Column 1: Enter the primary reservation name (example: Crow Creek)

Column 2: Enter the name of the parent (only one parent) (Complete Name: Last Name, First Name, and Middle Initial)

Column 3: Enter “R” if the parent in column 2 resided on the property identified in column 4, and enter “E” if the parent in column 2 was employed on the property identified in column 4.

Column 4: Enter the complete address or legal description. The local BIA/Tribal Official/Tax assessor may be able to assist the school district with providing this information.

Column 5: Enter “R” if the address is restricted property, enter “T” if the address is trust property, or “LR” if the address is leased restricted property.

Column 6: Enter “YES” or “NO” regarding whether the land is taxable, for leased restricted property only.

Column 7: Enter the student’s complete name (Last Name, First Name, and Middle Initial).

Column 8: Enter the date of birth

Column 9: Enter grade level of the student

The required signatures are:


CERTIFICATION OF PARENT/CHILD ELIGIBILITY:




  • The BIA/Tribal official certifies that each parcel indicated on the source check form is in trust or restricted status.

  • The tax assessor certifies that each parcel of leased, restricted property listed is not taxable and is exempt from state and local property taxes for school current expenditures purposes.


CERTIFICATION OF PARENT/CHILD ELIGIBILITY:



  • The tribal official will certify the residence of the parent or guardian of each pupil claimed, and will certify that the parent or guardian of each pupil claimed resides on eligible Indian Lands or is employed on eligible Indian Lands.




  • An authorized school official, or their designee or representative, certifies the name, Date of Birth (D.O.B.), grade level, and that the child was enrolled in the school system on the survey date.



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