MONTGOMERY COUNTY PUBLIC SCHOOLS

MONTGOMERY COUNTY PUBLIC SCHOOLS
Division of Controller / 45 W. Gude Drive, Room 3201 / Rockville, MD 20850 / 301-279-3039
FEDERAL IMPACT AID SURVEY as of September 30, 2015
STUDENT INFORMATION
Student's Last Name
Student's First Name
Student ID #
Sch #
School Name
Address
Fed Code
Student’s Birth Date
Grade
Phone
If the above property is a Federal property, enter the name
FOR SCHOOL USE ONLY
Active IEP on Sept 30, 2015?
□ Yes □ No
PARENT/GUARDIAN EMPLOYMENT INFORMATION (ADDRESS REQUIRED): CIVILIAN ( RESIDING IN MONT CO & EMPLOYED AT FEDERAL LOCATION IN MD )
Parent/Guardian Last Name
Parent/Guardian First Name
Name of Parent/Guardian Employer



Address of Parent/Guardian Employer (Required)


Number & Street
City
State
Zip Code
Number & Street
City
State
Zip Code
Name of Federal Property (see list below) (Required)

Address of Federal Property (Required)

PARENT/GUARDIAN EMPLOYED ON/REPORTED TO THE FEDERAL PROPERTY BELOW: CIVILIAN ( RESIDING IN MONT CO & EMPLOYED AT FEDERAL LOCATION IN MD )

Andrews AFB - 1500 W. Perimeter Rd, Andrews AFB, MD 20762

Nat’l Library of Medicine - 8600 Wisc Ave/Rockville Pk, Bethesda, MD 20894

Army Research Lab - 2800 Powder Mill Rd, Adelphi, MD 20783

Nat’l Security Agency – 9800 Savage Rd, Fort Meade, MD 20755

Dept of Defense Unif Serv Univ of Health - 4301 Jones Bridge Rd, Bethesda, MD 20814

Naval Medical Research Ctr - 503 Robert Grant Ave, Silver Spring, MD 20910

Dept of Energy - 19901 Germantown Rd, Germantown MD 20874

Naval Surface Warfare Center - 9500 McArthur Blvd, West Bethesda, MD 20817

FDA - 10903 New Hampshire Ave, Silver Spring, MD 20993

NGA - 4600 Sangamore Rd, Bethesda, MD 20816

FDA - 5100 Paint Branch Pkwy, College Park, MD 20740

NOAA National Weather Service - 1335 East West Hwy, Silver Spring, MD 20910

FDA – 8401 Muirkirk Rd, Laurel, MD 20708

Nuclear Regulatory Commission - 11555 Rockville Pk, Rockville, MD 20852

Fort Detrick - Frederick, MD 21702

Social Security Administration - 6401 Security Blvd, Baltimore, MD 21235

Fort Meade - 4409 Llewellyn Ave, Ft Meade, MD 20755

Social Security Administration - 7500 Security Blvd, Baltimore, MD 21244

IRS - 5000 Ellin Rd, Lanham, MD 20706

Walter Reed Nat’l Mil Med Ctr - 8901 Rockville Pk/Wisc Ave, Bethesda, MD 20889

NASA - 8800 Greenbelt Rd, Greenbelt, MD 20771

U.S. Census Bureau - 4600 Silver Hill Rd, Suitland, MD 20746

Nat’l Archives at College Park - 8601 Adelphi Rd, College Park, MD 20740

USDA - 10300 Baltimore Ave, Beltsville, MD 20705

Nat’l Institute of Standards & Tech - 100 Bureau Dr, Gaithersburg, MD 20899

U.S. Naval Academy - 121 Blake Rd, Annapolis, MD 21402

Nat’l Institutes of Health - 9000 Wisc Ave/Rockville Pk, Bethesda, MD 20892

Other (Name):
PARENT/GUARDIAN CONTRACTORS WORKING ON FEDERAL PROPERTY: CIVILIAN

Contractor who reported directly to work on the federal property above on survey date.

Contractor who reported to employer address before reporting to work on the federal property above on survey date.
EMPLOYMENT INFORMATION: UNIFORMED SERVICE (ACTIVE DUTY ONLY)
Parent/Guardian Last Name
First Name


EMPLOYMENT INFORMATION: FOREIGN MILITARY (ACTIVE DUTY ONLY)
Parent/Guardian Last Name
First Name


Branch of Service (Required)

Rank / Grade (Required)

Branch of Service (Required)

Rank / Grade (Required)

Name of Foreign Government
Active Duty / Retired
PARENT/GUARDIAN SIGNATURE - Certifying that all typed and written information on this form is accurate and complete on the survey date.
Print Name of Parent/Guardian
Note - Date Required
________________________________________________
Signature of Parent/Guardian
________________________________________________
Date
_________________________
Return Information - The survey can be returned to:
E-mail: [email protected] by Fax: 301-279-3031, or mailed to the address above
The information requested on this form will only be used to help determine the amount of funding available for MCPS under the Impact
Aid Program (Title VIII of the Elementary and Secondary Education Act), and may be provided to the U.S. Department of Education as of
the official survey date of September 30, 2015.
MCPS Form 280-4 9/15
Federal Impact Aid Survey Form, September 30, 2015
MONTGOMERY COUNTY PUBLIC SCHOOLS
Dear Parent/Guardian,
Please return this form only if you are on active duty
with the uniformed services, employed on federal
property, reside in federal or public housing, or are a
foreign government military officer.
If necessary, additional survey forms may be
obtained
on
the
Internet
at
www.
montgomeryschoolsmd.org/Departments/Forms/
PDF/280-4.PDF.
If you have any questions
regarding this survey, please call the Division of
Controller at 301-279-3039.
Thank you.
Please complete a separate survey form for each
student in your household. Remember to sign and
date the survey form. All information will be treated
confidentially.
Sincerely,
Please complete and return your survey by
December 18, 2015
Susanne G. DeGraba
Chief Financial Officer
FOLD HERE
DROP IN ANY MAILBOX
NO STAMP NEEDED
FOLD HERE
NO POSTAGE
NECESSARY
IF MAILED
IN THE
UEITED STATES
BUSINESS REPLY MAIL
FIRST CLASS MAIL PERMIT NO. 216 ROCKVILLE MD
POSTAGE WILL BE PAID BY ADDRESSEE
MONTGOMERY COUNTY PUBLIC SCHOOLS
DIVISION OF CONTROLLER – FIA SURVEY
45 W. GUDE DRIVE, ROOM 3201
ROCKVILLE MD 20850