McLoud Public Schools Grade____________



McLoud Public Schools

2014-2015 Federal Survey (Impact Aid)

Public Law 81-874, Survey date: September 1, 2014

A. PUPIL DATA

1. Name of Pupil: ____________________________________________________________

LAST FIRST MIDDLE

2. Birth Date _______/_______/_______ Age_______ Grade_____ School______________

3. Pupil’s Address on September 1, 2014

________________________________________________________________________________

Street City Zip

Is the above address on Federal Property or Indian Trust Land: Yes _____ No _____

If yes, give name and address of Federal Property or Tribe.

Name: ___________________________________________________________________

Address: _________________________________________________________________

B. EMPLOYMENT DATE (Civilian working on Federal/Tribal Property or Indian Casino)

1. Was the parent/guardian with whom pupil resides employed on Federal or Tribal

Property on September 1, 2014? Yes _______ No _______

If yes, give name and address of Federal Property (Tinker)/Tribal Property/or Casino

Name: __________________________________________________________________

Address: ________________________________________________________________

2. Name of employed parent/guardian as it appears on payroll:

________________________________________________________________________

3. Name and address of employer: ______________________________________________

______________________________________________

______________________________________________

C. EMPLOYMENT DATA (Uniformed services only/Army, Navy, Air Force, Marines)

1. Was either parent/guardian on active duty in the Uniformed Services on

September 1, 2014? Yes ______ No ______

If yes, complete item 2 below:

2. Name__________________________ Rank__________ Branch of Service____________

D. RANCHING/GRAZING/FARMING/LOGGING SECTION (IF APPLICABLE)

1. Did parent/guardian spend 50% or more of the days between July 1 and September 1, 2014

Ranching, grazing, farming, or logging on Federal Property? Yes ______ No ______

2. Name and address of the Federal Property on which the parent/guardian ranched, grazed, farmed

Or logged between July 1 and September 1, 2014. (Include section, township and range)

______________________________________________________________________

3. Name and address of employer between July 1 and September 1, 2014.

______________________________________________________________________

4. Occupation of parent/guardian on Federal Property: ____________________________

E. I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT:

______________________________________________ ______________________

Parent/Guardian Signature Date

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