7/22/2014

SAMPLE Impact Aid Program Source Check FormSAMPLE

ANCSA Indian Lands PropertyONLY: ClaimedonTables 1,3 or 5

Application Fiscal Year: ______School Year: ______

LEA Name: ______Survey Date: ______IAP Application Table:____(List only one table and property per form)

Name of ANCSAProperty Claimed ______

Complete Address/Property Description______

Application Number______

Location of property claimed as Title VIII Indian lands on
Table 1, 3 or 5 of application. / ANCSA
(yes
or
no) / Taxable
(yes
or
no) / 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 3 resided on the property identified in Column 4.
Enter E if parent in Column 3 was employed on the property identified in Column 4.

SAMPLE Impact Aid Program Source Check FormSAMPLE

ANCSA Indian Lands Property only: ClaimedonTables (1,3 or 5)

Application Fiscal Year: ______School Year: ______

LEA Name: ______Survey Date: ______IAP Application Table:____ (List only one table and property per form)

I hereby certify that on the survey date, each parcel of property (column 4) indicated as being “ANCSA” property in column (5) has been conveyed

under the Alaska Native Claims Settlement Act (ANCSA) to a Native individual, Native group, corporation organized under section 1613(h)(3) of

ANCSA, or a Village or Regional Corporation.

______

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

I hereby certify that on the survey date, each parcel of property(column 4)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

______

I hereby certify that the information shown under column 1, 2, 3, 4, and 7 is correct as of the survey date.

______

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

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

8 and 9 is correct.

______

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

ANCSA Indian Lands Source Check Form Instructions

Alaska Local Education Agencies Only claiming children on Table 1 or 3 as residing on ANCSA Lands, or on Table 5 as residing with a parent employed on ANCSA Lands

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

ANCSA Land is real property that is tax-exempt due to Federal law, agreement or policy and that was conveyed under the Alaska Native Claims Settlement Act (ANCSA) to a Native individual, Native group, corporation organized under section 1613(h)(3) of ANCSA, or village or Regional Corporation, as those terms are defined in ANCSA (“ANCSA” property). A parcel is still eligible even if it changed hands, if it was conveyed at any time under ANCSA and is still tax-exempt.

The LEA provides the ANCSA 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 as being “ANCSA” property in column 4 has been conveyed under the Alaska Native Claims Settlement Act (ANCSA) to a Native individual, Native group, corporation organized under section 1613(h)(3) of ANCSA, or a Village or Regional Corporation.
  • Tax assessor, who certifies that each parcel indicated on the source check as being not taxable is exempt from state and local real property taxes for elementary and secondary school current expenditure purposes, and that this exemption is due to federal law, agreement or policy.
  • Certifying tribal official, who certifies the residence of the parent or guardianof each pupil claimed, and who certifies that the parent or guardian of each pupil claimed resides on or is employed on Indian lands.
  • Anauthorized 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: School officials complete the entire box at 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

Name of ANCSA Property Claimed: Enter the name of the property claimed

Complete Address/ Property Description: Enter complete address or legal description of the ANCSA Land claimed

Application Number: Enter the Impact Aid application number of the LEA

Complete Columns

Column 1: Enter the primary reservation or other locator name

Column 2: Enter the complete name (first and last name) of the parent (only one parent)

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 wasemployed on the property identified in column 4.

Column 4: Enter the complete address or legal description. The tribal official may be able to assist the school district with providing this information.

Column 5: Enter “YES” or “NO”regarding whetherthe address is ANCSA land.

Column 6: Enter “YES” or “NO” regarding whether the land is taxable.

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

Column 8: Enter the Date of Birth

Column 9: Enter Grade of the student

The required signatures are:

  • The Tribal/Certifying Official will certify that each parcel indicated on the source check list as being “ANCSA” property in column 4 has been conveyed under the Alaska Native Claims Settlement Act (ANCSA) to a Native individual, Native group, corporation organized under section 1613(h)(3) of ANCSA, or a Village or Regional Corporation on the survey date.
  • The tax assessor will certify that each parcel indicated on the source check as being not taxable is exempt from state and local real property taxes for elementary and secondary school current expenditure purposes, and that this exemption is due to federal law, agreement or policy on the survey date.
  • 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 or is employed on eligible Indian lands.
  • Authorized school official, 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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