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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