ST. MARY'S COUNTY PUBLIC SCHOOLS - IMPACT AID PROGRAM SURVEY FORM We have preprinted your information on this form. If correct, please sign and date below, and return to the school your child attends. Please cross out any incorrect information and make the correction in the space allotted. ALL BOXES MUST BE FILLED IN WITH COMPLETE INFORMATION IF APPLICABLE. Thank you for your cooperation. The survey date is September 30, 2018.

FILL IN THE BOXES BELOW WITH COMPLETE AND ACCURATE INFORMATION. SECTION A: STUDENT INFORMATION Student's Last Name Student's First Name and Middle Initial Date of Birth Grade Student ID School Name Teacher

Address City State Zip

Does the student reside on federal property? Yes No If Yes, check one of the options to the right. Naval Air Station Patuxent River Glenn Forest If the above property is a federal property, enter the name of the property. Name of Federal Property School Use Only Active IEP on September 30, 2018? SECTION B: PARENT OR GUARDIAN INFORMATION WITH WHOM THE STUDENT RESIDES PLEASE CLEARLY CHECK OR WRITE IN APPROPRIATE BOXES BELOW IF YOUR WORKSITE IS NOT LISTED. , 6170 Guardian Gateway, Aberdeen Proving Ground, MD 21005 National Geospatial Intelligence/Imagery Map, 4600 Sangamore Road, , 1500 Perimeter Road, Andrews, Camp Springs, MD 20762 Bethesda, MD 20816 Washington National Federal Records Center, 4205 Suitland Road, Suitland, MD 20746 National Institute of Health, 9000 Wisconsin Avenue/Rockville Pike, Army Research Lab (Adelphi Laboratory Center), 2800 Powder Mill Road, Adelphi, MD 20783 Bethesda, MD 20892 Beltsville Human Nutrition Research Center, 10300 Baltimore Avenue, Beltsville, MD 20705 National Maritime Intelligence Center, 4600 Silver Hill Road, Suitland, MD 20746 Baltimore Washington Parkway (Gladys Noon Spellman), 6565 Greenbelt Road, Naval Intelligence, 4251 Suitland Road, Suitland, MD 20746 Greenbelt, MD 20770 Naval Academy, 121 Blake Road, Annapolis, MD 21412 Census Bureau-Science Technology Building, 17101 Melford Boulevard, Bowie, Naval Air Station (NAS Patuxent River), 22268 Cedar Point Road, Naval Air Station MD 20715 Patuxent River, MD 20670 Census Bureau,Federal Office Building, 4600 Silver Hill Road, Suitland, MD 20746 Naval Intelligence Support Center, Chesapeake Beach Detachment 5813, Bayside Coast Guard Cove Point Light Station, 3500 Lighthouse Road, Lusby, MD 20657 Road, Chesapeake Beach, MD 20732 Architect of Capital (Senate), 6330 Columbia Pike Road 1535/1553/1575, Cabin Naval Ordnance Lab Test Facility, 13855 Solomons Island Road, Solomons, MD 20688 Branch Drive, Landover, MD 20785 Naval Propellant Plant (NSWC) Stump Neck, 3767 Strauss Avenue, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, Indian Head, MD 20640 MD 20889 Naval Reconnaissance Technical and Support Center, 4600 Silver Hill Road, Federal Aviation Administration Radar Tracking Station, 4213 Suitland Road-Silver Hill Suitland, MD 20746 Road, Suitland, MD 20746 Federal Office Building, Module II, 8401 Muirkirk Road, Laurel, MD 20708 Federal Law Enforcement Training Center, 9000 Commo Road, Cheltenham, Naval Research Lab, Pomonkey 10050 Blossom Point Road, Welcome, MD 20693 MD 20623 Naval Station, 58 Bennion Road, Annapolis, MD 21402 Federal Office Building # 4, 4401 Suitland Road, Suitland, MD 20746 Naval Surface Warfare Center, 3767 Strauss Avenue, Indian Head, MD 20640 Federal Research Center White Oak, 10903 New Hampshire Avenue, New Carollton Federal Building Internal Revenue Service, 5000 Ellin Road, Silver Spring, MD 20993 New Carrollton/Lanham, MD 20706 Food and Drug Administration, College Park Campus OFC, 5100 Paint Branch Parkway National Oceanic and Atmospheric Administration Satellite Operations Facility, 4231 and River Road, College Park, MD 20740 Suitland Road, Suitland, MD 20746 Fort Meade, 4409 Llewellyn Avenue, Fort Meade, MD 20755 One White Flint North, 11555 Rockville Pike, Bethesda, MD 20852 General Services Administration Building ( Department of Agriculture), Silver Spring Metro Center # 1, 1335 East West Highway, Silver Spring, MD 20910 10300 Baltimore Avenue, Beltsville, MD 20705 Smithsonian Storage Facility, 3910 and 4210 Silver Hill Road, Suitland, MD 20746 General Services Administration Office, 4150 Silver Hill Road, Fort Washington, MD 20744 Suitland House, 4510 Silver Hill Road, Suitland, MD 20746 National Aeronautics Space Administration, Goddard Space Flight Center, 8800 Nike Missle Site, W-92 Timberbrook Lane, Gaithersburg, MD 20878 Greenbelt Road, Greenbelt, MD 20771 Federal Office Building # 3, 4700 Silver Hill Road, Suitland, MD 20746 United States National Agricultural Library, 10301 Baltimore Avenue, Beltsville, MD 20705 Social Security Administration Building, 7500 Security Boulevard, Woodlawn, MD 21244 Naval Electronic Systems Engineering (NESEA/Webster Field), 4700 Villa Road, St. Inigoes, MD 20684 SECTION C: CIVILIAN: PARENT/GUARDIAN EMPLOYMENT INFORMATION Was either parent/guardian with whom the student resides employed on Federal Property in on September 30, 2018? YES (please complete this section. Enter parent/guardian name as shown on employer payroll record). NO (please sign/date below and return the form to your child's school). Name of Parent/Guardian's Employer (required-complete name of Parent/Guardian's Last Name First Name and Middle Initial branch/division)

Address of Parent/Guardian's Employer (required) City State Zip

Name of Federal Property

Street Address of Federal Property (required) City State Zip

SECTION D: UNIFORMED SERVICES: PARENT/GUARDIAN EMPLOYMENT INFORMATION Was either parent/guardian with whom the student resides on active duty in the Uniformed Services* on September 30, 2018? YES NO (if YES, please complete this section. If branch and rank are not filled in, form cannot be processed. [Per United States Department of Education]). *Air Force, Army, Coast Guard, Marine Corps, Navy, NOAA Corps, Public Health Service, Reserves, or National Guard on the survey date. Parent/Guardian's Last Name First Name and Middle Initial Branch of Service (required) Rank

If on ACTIVE DUTY in RESERVES or NATIONAL GUARD on September 30, 2018, please attach a COPY OF YOUR ORDERS. (you may blacken out all info except name/rank/branch of service/title no). If orders are unavailable, please provide name/phone # of supervisor who can verify your active duty status. Name of Supervisor: Supervisor Phone Number: SECTION E: FOREIGN MILITARY: PARENT/GUARDIAN EMPLOYMENT INFORMATION Enter information in this section regarding the parent/guardian if either person was both an accredited foreign government official and a foreign military officer on the survey date. Parent/Guardian's Last Name First Name and Middle Initial Branch of Service (required) Rank

Name of Foreign Government This information is the basis for payment to St. Mary’s County Public Schools of federal funds under the Impact Aid Program (Title VII of the Elementary and Secondary Education Act), and may be provided to the US Department of Education if St. Mary’s County Public Schools’ application for payment is audited. This form must be signed and dated for St. Mary's County Public Schools to receive funds based on this information. By signing this form, I am certifying that all typed and written information on this form is correct as of September 30, 2018.

Signature of Parent / Guardian Date