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To:<br />

From:<br />

OAKLAND UNIFIED SCHOOL DISTRICT<br />

Office of State Administrator<br />

March 26, 2008<br />

LEGISLATIVE FILE<br />

<strong>File</strong> <strong>In</strong> <strong>No</strong>. <strong>tJ</strong> ~- 6 <strong>Obb</strong><br />

Vincent Matthews, State Administrator <strong>In</strong>troduction Date ,~/J.fo/Of---<br />

Board of Education Enactment <strong>No</strong>...... _<br />

Enactment Date _<br />

Leon Glaster, CFO/Associate Superintendei _<br />

Valerie Williams, Grant Writer Y<br />

Subject: Approval and Support by the State Administrator of the District<br />

Submitting the Impact Aid Grant Application for OUSD Schools for<br />

Fiscal Year 2008-2009<br />

ACTION REOUESTED:<br />

Approval and support by the State Administrator of the District submitting the<br />

Impact Aid Grant Application for OUSD schools for fiscal year 2008-2009 and to<br />

accept same, if granted, in whole or in part, pursuant to the terms and conditions thereof<br />

and to submit amendments thereto, for the grant year, if any.<br />

BACKGROUND:<br />

The Impact Aid Grant Application for OUSD schools for the 2008-2009 fiscal year was<br />

submitted for funding as indicated in the chart below. The grant application packet is<br />

available for review through the Board Secretary's Office and will be electronically<br />

available within one week of the board meeting through Legistar.<br />

<strong>File</strong>lD Backup Applicant Grant's Purpose Time Period Funding<br />

# Document Source<br />

<strong>In</strong>cluded<br />

08-0555 X OUSD for District-wide Economic Impact Aid 7/1/08-6/30/09 Amount by TBD<br />

funding. to apply for OUSD by U.S. Dept of<br />

funding outlining<br />

students housed in<br />

Education<br />

Public Housing as<br />

identified by Oakland<br />

Housine Authority.<br />

RECOMMENDATION:<br />

Approval and support by the State Administrator of the District submitting Impact Aid<br />

Grant Application for OUSD schools for fiscal year 2008-2009 and to accept same, if<br />

granted, in whole or in part, pursuant to the terms and conditions thereof and to submit<br />

amendments thereto, for the grant year, if any.


FISCAL IMPACT:<br />

The number is To Be Determined by Funder.


Impact Aid # 140430<br />

U.S. Department of Education<br />

Washington, D.C. 20202-5335<br />

APPLICATION FOR GRANTS<br />

UNDER THE<br />

IMPACT AID FY 2009 SECTION 8003 APPLICATION PACKAGE<br />

CFDA # 84.0418<br />

Impact Aid # 140430 -- Version # 1<br />

OMB <strong>No</strong>. 1810-0036, Expiration Date: 06/3012008<br />

Closing Date: JAN 31, 2008


Forms<br />

**Table of Contents**<br />

i. impact Aid, Sec. 8003 Cover Page _<br />

2. impact Aid, Sec. 8003 Assurances _<br />

3. impact Aid, Sec. 8003 Table l - Live-on & Work-on, CWD _<br />

4. impact Aid, Sec. 8003 Table 2 - Live-off, CWD _<br />

5. impact Aid, Sec. 8003 Table 3 - Live-on & Work-on _<br />

6. impact Aid, Sec. 8003 Table 4 - Live-on & Low-Rent Housing _<br />

7. impact Aid, Sec. 8003 Table 5 - Work-on _<br />

8. impact Aid, Sec. 8003 Table 6 - Membership & ADA _<br />

9. impact Aid, Sec. 8003 Table 9 - Military Housing Renovation _<br />

l o. impact Aid, Sec. 8003 Table l l «<strong>In</strong>dian Housing Renovation _<br />

This application was generated using the PDF functionality. The PDF functionality automatically numbers the pages in this application.<br />

Some pages/sections of this application may contain 2 sets of page numbers, one set created by the applicant and the other set created by<br />

e-Application's PDF functionality. Page numbers created by the e-Application PDF functionality will be preceded by the letter e (for<br />

example, el, e2, e3, etc.).<br />

Impact Aid # 140430<br />

el<br />

e2<br />

e3<br />

e5<br />

e6<br />

e8<br />

elO<br />

el2<br />

el3<br />

el4


Final Filing Date: 01/31/2008 U.S. Department of Education Form Approved:<br />

Applicants must submit complete<br />

applications (ED Form 4019)<br />

on or before this filing<br />

deadline to receive full<br />

payments. See the instructions<br />

for further information.<br />

MEMBERSHIP SURVEY DATE<br />

Impact Aid # 140430 e1<br />

Impact Aid Program -OMB no. 1810-0036<br />

Washington, DC. 20202-6244 -Expiration date: 06/3012008<br />

APPLICATION FOR IMP ACT AID - SECTION 8003<br />

Submit an original and 1 copy to the Impact Aid Program.<br />

Send 1 copy to the State Educational Agency(SEA) using the attached transmittal form.<br />

0iersion <strong>No</strong>. I)<br />

IMPACT AID #: 14-CA-2009-0430<br />

SURVEY FORMS :0 ORIGINAL APPLICATION: Ii1I<br />

First (Required) : 12/11/2007 PRlAWARD #: S04IB-2009-0796<br />

Second (Optional) ; SOURCE CHECK: Ii1I AMENDMENT: 0 DUNS # : 07-655-4500<br />

APPLICANT NAME : Oakland Unified School District CONTACT PERSON NAME: Leon Glaster<br />

STREETIP.O. BOX : 1025 Second Avenue TITLE: CFO<br />

CITY : Oakland PHONE: (510) 879-4628<br />

COUNTY : Alameda FAX: (510) 879-8836<br />

STATE&ZIP :CA 94606- E-MAIL: Leon.Glaster@ousd.kI2.ca.us<br />

o CHECK TO APPLY FOR FUNDING UNDER SECTION 8003(b)(2) FOR HEA VILY IMPACTED LEAs. (If you check this box, the Impact Aid Program<br />

will contact you to request additional information.)<br />

GRADE SPAN MAINTAINED LEGAL CLASSIFICATION (If different from grade span)<br />

K-12<br />

I certify that I have read the statements contained in this application and that these statements and all of the data included in this application are, to<br />

the best of my knowledge and belief, true, complete, and correct. I certify that I am authorized to make the representations and commitments in this<br />

application, for and on behalf of the applicant and otherwise to act as the applicant's authorized representative in submitting this application for funding<br />

under section 8003 of the Impact Aid Program (Title V<strong>In</strong> of the Elementary and Secondary Education Act). I declare that the applicant will mail a complete<br />

copy of this application to the SEA at the same time that it mails this application to the U.S. Department of Education. A<br />

NAME AND TITLE OF AUTHORIZED REPRESENTATIVE (Please type or print.)<br />

\\1al) Neia-ye<br />

FiMBMGial Asa 8 eeeant Lelfl Gla5f-u- dt'£ nnf'.{V'JOJ ~,', ~~ .=,()-<br />

./<br />

ED 4019 Revised 05/3112005<br />

DATE<br />

[--1116/20083:33:40 PM


OMB NO.1810-0036 Exp.06/30/2008<br />

ED 4019 Revised 05/3112005<br />

IMPACT AID PROGRAM ASSURANCES AND CERTIFICATIONS (verelcn <strong>No</strong>.1)<br />

Applicant Name: Oakland Unified School District IImpact Aid Number: 14-CA-2009-0430 I School Year: 2007-2008<br />

The local educational agency (LEA) hereby declares that it has filed the following assurances and certifications covering the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act(ESEA) with<br />

the U.S. Department of Education, and, as of the date of the signature below, reaffirms and incorporates by reference those assurances and certifications in this Impact Aid application. * The LEA cerifies that no<br />

circumstances affecting the validity of the following assurances have changed since their previous filing:<br />

•<br />

•<br />

•<br />

As applicable, the assurances in OMB Standard Form 424B (Assurances for <strong>No</strong>n-Construction Programs), relating to legal authority to apply for assistance; access to records; conflict of interest; merit systems;<br />

nondiscrimination; Hatch Act provisions; labor standards; flood insurance; environmental standards; wild and scenic river systems; historic preservation; protection of human subjects; animal welfare; lead-based<br />

paint; Single Audit Act; and general agreement to comply with all Federallaws, executive orders and regulations;<br />

The certification regarding lobbying in ED Form 80-0013; and<br />

With respect to the Certification Regarding Lobbying, the LEA recertifies that no Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or<br />

employee of Congress, or an employee of a Member of Congress in connection with the making or renewal of Federal grants under this program; that the LEA will complete and submit Standard Form LLL,<br />

"Disclosure Form to Report Lobbying," when required (34 CFR Part 82, Appendix B); and that the LEA will require the full certification, as set forth in 34 CPR Part 82, Appendix A, in the award documents for<br />

all subawards at all tiers.<br />

The LEA further assures that:<br />

•<br />

•<br />

•<br />

•<br />

•<br />

It is a local educational agency that was created and authorized to operate schools, has administrative control and direction of free public education in the school districts, and that it may legally accept and<br />

disburse Federal funds to aid in financing its expenditures;<br />

It will comply with all applicable statures, regulations, and requirements concerning this grant, including requirements of the Impact Aid law (Title VIII of the ESEA), the program regulations (34 CFR Part 222),<br />

and program administrative requirements:<br />

It will use fiscal control and fund accounting procedures that will ensure proper disbursement of, and accounting for any Impact Aid payments received for federally connected children with disabilities claimed<br />

on Tables 1 and 2. and will use those funds to provide a free appropriate public education to those children in accordance with the <strong>In</strong>dividuals with Disabilities Education Act (IDEA)(20 U.S.C., 1400 et seq.).<br />

The special education programs provided to the children with disabilities claimed in this application conform to the policies, procedures and requirements of the (IDEA);<br />

For any children claimed who reside on eligible <strong>In</strong>dian lands, policies and procedures have been established as required by section 8004 of'the Impact Aid law, and have been adequately disseminated to the<br />

tribes and parents of children residing on eligible <strong>In</strong>dian lands. A copy of the current policies and procedures or a waiver statement from the local <strong>In</strong>dian tribe(s) is attached (sec instructions for further<br />

information); and<br />

It is hereby advised thai, under section 8011 of the Impact Aid law, it is entitled to request an administrative hearing on, andlor review or reconsideration of, any action of the Department under the Impact Aid<br />

law that adversely affects or aggrieves the applicant; any such requests are governed by the regulations in 34 CFR Part 222, Subpart J, except for requests for hearings concerning <strong>In</strong>dian policies and procedures,<br />

tribal complaints, and withholdings that are governed by the regulations at 34 CFR Part 222, Subpart G. Any request for a hearing, review or reconsideration under 34 CFR Part 222, Subpart J, must be made in<br />

writing and submitted within 60 calendar days from the date of the applicant's notice (receipt) of the adverse action to: Director, Impact Aid Program, United States Department of Education, 400 Maryland<br />

Ave., SW. Washington, D.C. 20202-6244.<br />

*If the applicant is applying for Impact Aid assistance for the first time, the applicant also must file with the Impact Aid Program by the deadline for filing this application the following assurances and certification that it<br />

can obtain from the lAP: OMB Standard Form 424B (Assurances for <strong>No</strong>n-Construction Programs) and ED Form 80-00B (certification :gardi';,!07g) .<br />

- Leon Glaster -'<br />

CPO ./7~<br />

1116/2008<br />

Name and Title of Authorized Certifvin" Renresentatlve ~ Sienature ,- Wate -<br />

Impact Aid # 140430 e2<br />

,-;


OMB <strong>No</strong>.181O-0036 Exp.06/30/2008<br />

ED 4019 Revised 05/3112005<br />

Application For Impact Aid Section 8003 • Table 1 (Version <strong>No</strong>.1)<br />

Applicant Name: Oakland Unified School District Impact Aid Nnmber: School Year: 2007-2008<br />

14-CA-2009-0430<br />

Table 1: Children with disabilities who: (1) Reside on eligible federal property and have a parent on active duty in the<br />

uniformed services of the United States; or (2) Reside on eligible federal property with a parent who is both an<br />

accredited foreign government official and a foreign military officer; or (3) Reside on eligible <strong>In</strong>dian lands<br />

(<strong>In</strong>clude only children enrolled in State-approved special education programs on this table. Exclude these children from<br />

Tables 2,3,4, and 5.)<br />

Table 1-1. Federal Property on which children with disabilities reside<br />

Property Code Number Official Name, Address, City, State Property Type Number of<br />

children on survey<br />

(1) (2) (3) date<br />

(4)<br />

Impact Aid # 140430 e3<br />

Table 1-1 Total => 0


Table 1-2. Children with disabilities<br />

Number of<br />

Property Code children on survey<br />

Number Children with disabilities date<br />

(4) (5) (6)<br />

14-0000-0010* With a parent on active duty in the uniformed services of the United States<br />

14-0000-0015* With a parent who is both an accredited foreign government official and a foreign military<br />

officer<br />

14-1435-0010* Residing on eligible <strong>In</strong>dian lands<br />

Impact Aid # 140430 e4<br />

..<br />

*NOTE: Property codes marked with an asterisk will always be the same. Table 1-2 Total -> 0<br />

<strong>No</strong>te: Table 1-1 Total and Table 1-2 Total must be the same. Table 1-2 is a summary of all children on Table 1-1.<br />

Properties listed on this page were claimed in the LEA's prior year application. An LEA may add any property it believes is eligible,<br />

without a property code number. However, it must iodicate the specific location of each parcel of claimed property (i.e., the official<br />

name, street address, city, and state).


OMB <strong>No</strong>.1810-0036 Exp.06l30/2008<br />

ED 4019 Revised 05/3112005<br />

Application For Impact Aid Section 8003 - Table 2 (Version <strong>No</strong>.1)<br />

Applicant Name: Oakland Unified School District Impact Aid Number: School Year: 2007-2008<br />

14-CA-2009-0430<br />

Table 2: Children with disabilities who DO NOT RESIDE ON FEDERAL PROPERTY BUT: (1) Have a parent on active duty<br />

in the uniformed services of the United States; or (2) Have a parent who is both an accredited foreign government<br />

official and a foreign military officer<br />

(<strong>In</strong>clude only children enrolled in state-approved special education programs on this table. Exclude these children from Tables<br />

1,3,4, and 5.)<br />

Number of children on survey<br />

Property Code Number Children with disabilities date<br />

(1) (2) (3)<br />

14-0000-001 0 With a parent on active duty in the uniformed services of the United States 0<br />

14-0000-0015 With a parent who is both an accredited foreign government official and a 0<br />

foreign military officer<br />

Impact Aid # 140430 e5<br />

Table 2 Total => 0


OMS <strong>No</strong>.1810-0036 Exp.06/3012008<br />

ED 4019 Revised 05/3112005<br />

Application For Impact Aid Section 8003 - Table 3 (Version <strong>No</strong>.1)<br />

Applicant Name: Oakland Unified School District Impact Aid Number: School Year: 2007-2008<br />

14-CA-2009-0430<br />

Table 3: Children who: (1) Reside on federal property with a parent employed on eligble federal property located at least partly<br />

within the school district; or (2) Reside on eligible federal property and have a parent on active duty in the uniformed<br />

services of the United States; or (3) Reside on eligible federal property and have a parent who is both an accredited<br />

foreign government official and a foreign military officer; or (4) Reside on eligible <strong>In</strong>dian lands(no parental<br />

employment required) (Do not include children reported on Tables I.)<br />

Federal Property on which children reside Federal Property on which parents are employed Number<br />

of<br />

children<br />

Property Code Official Name, Address, City, Property Code Official Name, Address, City, on<br />

Number State Number State survey<br />

date<br />

(I) (2) (3) (4) (5)<br />

Impact Aid # 140430 e6<br />

.<br />

Table 3 Total => 0


Properties listed on this page were claimed in the LEA's prior year application. An LEA may add property it believes is eligible,<br />

without a property code number. However, it must indicate the specific location of each parcel of claimed property (i,e., the<br />

official uame, street address, city and state).<br />

Impact Aid # 140430 e7


OMS <strong>No</strong>.1810-0036 Exp.06f30/2008<br />

ED 4019 Revised 05/3112005<br />

Application For Impact Aid Section 8003 - Table 4 (Version <strong>No</strong>.1)<br />

Applicant Name: Oakland Unified School District Impact Aid Number: School Year: 2007-2008<br />

14-CA-2009-0430<br />

Table 4. Children who reside on eligible federal property but whose parents are not employed on federal property<br />

(Children residing on eligible <strong>In</strong>dian lands should be reported on Table 3.)<br />

Federal Property on which children reside Number of<br />

Property Code<br />

children on<br />

Number Official Name, Address, City, State survey date<br />

(1) (2) (3)<br />

1486300370 LRH Projects #3-1 (Peralta Village Apts) 103<br />

Oakland CA<br />

1486300371 LRHP #3-2 (Campbell Village Apts) 48<br />

OaklandCA<br />

1486300372 LRHP # 3-3 (Lockwood Gardens Apts) 143<br />

OaklandCA<br />

1486300373 LRHP #3-9 & 8C (Chestnut Court Apts) 0<br />

OaklandCA<br />

1486300375 LRHP # 3-8B & 11 (Coliseum Gardens Apts) 0<br />

Oakland CA<br />

1486300376 LRHP# 3-8D (Tassafaronga Village Apts) 48<br />

OaklandCA<br />

1486300378 LRHP # 3-8A, 13 -71, 73-78, 80, 98 & 99 1,040<br />

(Scattered Sites - Specific street addresses must be given)<br />

Impact Aid # 140430 e8


OaklandCA<br />

Table 4 Total => 1,382<br />

Properties listed on this page were claimed in the LEA's prior year application. An LEA may add property it believes is eligible,<br />

without a property code number. However, it must indicate the specific location of each parcel of claimed property (i.e., the<br />

official name, street address, city and state).<br />

Impact Aid # 140430 e9


OMB <strong>No</strong>.1810~0036 Exp.06/30/2008<br />

ED 4019 Revised 05/3112005<br />

Application For Impact Aid Section 8003 - Table 5 (Version NO.1)<br />

Applicant Name: Oakland Unified School District Impact Aid Number: School Year: 2007-2008<br />

14-CA-2009-0430<br />

Table 5. Children who do not reside on federal property but: (I) Reside with a parent employed on federal property; or (2)<br />

Have a parent on active duty in the uniformed services of the United States; or (3) Have a parent who is both an<br />

accredited foreign government official and a foreign military officer<br />

(Do not include children reported on Table 2.)<br />

Federal Property on which parents are employed Number of<br />

Property Code<br />

children on<br />

Number Official Name, Address, City, State survey date<br />

(I) (2) (3)<br />

1400000010 Uniformed Services 0<br />

xxxxCA<br />

Impact Aid # 140430 e10<br />

Table 5 Total => 0<br />

Properties listed on this page were claimed in the LEA's prior year application. An LEA may add property it believes is eligible,<br />

without a property code number. However, it must indicate the specific location of each parcel of claimed property (l.e., the


official name, street address, city and state).<br />

Impact Aid # 140430 e11


OMB <strong>No</strong>.1810-0036 Exp.06/30/2008<br />

ED 4019 Revised 05/3112005<br />

Table 6. Membership and Average Daily Attendance Data (Version <strong>No</strong>.1)<br />

Applicant Name: Oakland Unified School District Impact Aid Nnmber: School Year: 2007-2008<br />

14-CA-2009-0430<br />

Preceding Current<br />

I. Membership - total number of children enrolled in the preceding school year and the Year Year<br />

current school year on the respective survey date<br />

(A) in schools ofthe applicant's district (Do not include tuition-out children) L(A) 39,848 38,153<br />

(B) for whom tuition is received (tuition-in) L(B) 0 0<br />

(C) subtotal [line L(A) MINUS line L(B)] L(C) 39,848 38,153<br />

(D) for whom tuition was paid (tuition-out) L(D) 0 0<br />

(E) for whom the applicant school district provided free public elementary or secondary<br />

education [line L(C) PLUS line L(D)]<br />

L(E) 39,848 38,153<br />

2. Average daily attendance (ADA) for the preceding school year<br />

(ADA is defined as the aggregate number of days in attendance of all students during a<br />

school year divided by number of days school is in session during that year (section<br />

14101(1) of the ESEA).)<br />

(A) preceding "regular" school year ADA of all children reported on line I.(E) of this<br />

table<br />

(This line INCLUDES tuition-out children and EXCLUDES tuition-in children.)<br />

(Summer school ADA SHOULD NOT be included in this line.)<br />

(B) Hours of summer school attendance for the preceding school year<br />

(This line INCLUDES tuition-out children and EXCLUDES tuition-in children.)<br />

(C) Number of days in the regular school year<br />

(This line INCLUDES tuition-out children and EXCLUDES tuition-in children.)<br />

3. Total federally connected children claimed for the current year (2007-2008) from tables 1<br />

through 5.<br />

Impact Aid # 140430 e12<br />

2.(A) 37,158.77<br />

2.(B) 76,209.00<br />

2.(C) 180<br />

3. 1,382<br />

[LINE 3 Divide 1(E) Current Year] 3.62%


1-<br />

OMB <strong>No</strong>.1810-0036 Exp.06/30!2008<br />

ED 4019 Revised 05/31/2005<br />

Table 9. Military installation housing units undergoing renovation or rebuilding (Version <strong>No</strong>. 1)<br />

Applicant Name: Oakland Unified School District Impact Aid Number: School Year: 2007-2008<br />

14-CA-2009-0430<br />

<strong>In</strong>clude the housing units undergoing renovation or rebuilding on impact aid survey date shown on the cover page of this application. For<br />

each unit, list the specific address or quarters number, the number of school aged children expected to reside in housing unit, the date the<br />

housing unit was vacated or demolished, and, if applicable, the date funds became available for rebuilding the demolished housing.<br />

Documentation of the availability of funding must be provided for housing being rebuilt.<br />

(Col. I) (Col. 2) (Col. 3) (Col. 4)<br />

Specific Addresses or Quarters Numbers for the <strong>No</strong>. of School-aged Date Unit Vacated or If Unit Demolished, Date<br />

Housing Undergoing Renovation or Rebuilding Children Expected to Demolished Funds Became Available<br />

Reside in This Housing for Rebuilding (provide<br />

When Renovation or Documentation)<br />

Rebuilding is Complete<br />

Name of Military <strong>In</strong>stallation Base Housing Occupancy Rate: %<br />

I hereby certify that the above information is accurate and complete to the best of knowledge and the total number of children reported<br />

would have resided in the on-base housing listed above except that the housing was undergoing renovation or rebuilding on the Impact<br />

Aid survey date.<br />

SIGNATURE'5k DATE !NAME AND TITLE OF AUTHORIZED trELEPHONE NUMBER<br />

--;;/ ./.$ r / ~2° ., !REPRESENTATIVE<br />

C7 - °c<br />

Chief Financial Officer 510 879-8200<br />

"<br />

Impact Aid # 140430 e13


OMB <strong>No</strong>.1810·0036 Exp.06/3012008<br />

ED 4019 Revised 05/3112005<br />

Table 11. Housing on <strong>In</strong>dian Lands undergoing renovation or rebuilding (Version <strong>No</strong>.1)<br />

Applicant Name: Oakland Unified School District Impact Aid Number: School Year: 2007-2008<br />

14-CA-2009-0430<br />

List of housing located on <strong>In</strong>dian lands undergoing renovation on Impact Aid survey date shown on the cover page of this application by<br />

name, address, and type and identity the number of school-aged children associated with this housing.<br />

(Col. I) (Col. 2) (Col. 3) (Col. 4)<br />

Name (and Number, if Specific Address or Legal Description for Each Type of<strong>In</strong>dian Lands Where Number of School-<br />

Applicable) of Housing House or Unit Undergoing Renovation or Housing is Located(Trust, aged Children Who<br />

Development or Project Rebuilding Restricted, ANCSA, or Other Last Resided in<br />

Undergoing Renovation or Eligible <strong>In</strong>dian Lands) This Housing<br />

Rebuilding<br />

Certification by Housing or Tribal Official: I hereby certify that the information reported above is accurate and that the number of<br />

children listed in colunm 4 would have resided in this housing on <strong>In</strong>dian lands except that the housing was undergoing renovation or<br />

rebuilding on the survey date.<br />

Telephone<br />

Signature Date Name and Title Number<br />

Certification by Bureau of <strong>In</strong>dian Affairs or Tribal Official: I hereby certify that I have reviewed official records and have verified<br />

that this housing is located on <strong>In</strong>dian Lands as defined in sections 8013(5)(A)(ii) and 8013(7) of the Impact Aid Law. (See the application<br />

instructions for definitions.)<br />

I I I ., I<br />

Impact Aid # 140430 e14


Iisignature Ioate INarne and Title lNumber<br />

Impact Aid # 140430 e15


County: Alameda<br />

District: Oakland Unified<br />

CDS CODE_ OJ. 6J.259<br />

Regu1ar E1ementary and High School ADA<br />

Kindergarten<br />

Grades 1 - 3<br />

Grades 4 - 6<br />

Grades 7 - B<br />

Grades 9 - 12<br />

Continuation Education<br />

Opportunity Schools and Full-Day Opportunity<br />

Classes<br />

Home and Hospital<br />

Special Education - Special Day Class<br />

Special Ed - <strong>No</strong>npublic, <strong>No</strong>nsectarian Schools<br />

[E.C. 56366(a) (7)]<br />

Report of School District Attendance<br />

Special Ed - <strong>No</strong>npublic, <strong>No</strong>nsectarian Schools -<br />

Licensed Children\s <strong>In</strong>stitutions<br />

Community Day School (Divisor 70/135/180)<br />

Extended Year ADA (Divisor 175)<br />

Extended Year Special Education<br />

Extended Year Prog - <strong>No</strong>npublic, <strong>No</strong>nsectarian<br />

Schools [E.C. 56366(a) (7)]<br />

Extended Year Prog - <strong>No</strong>npublic, <strong>No</strong>nsectarian<br />

Schools - Licensed Children's <strong>In</strong>stitutions<br />

Regional Occupational Centers/Programs<br />

(Divisor 85/135/175)<br />

Classes for Adults ADA (Divisor 85/135/175)<br />

Concurrently Enrolled Secondary Students<br />

Adults Enrolled, State Apportioned<br />

Students 21 Years or Older and Students 19<br />

years or Older <strong>No</strong>t continuously Enrolled Since<br />

Their 18th Birthday, Participating in<br />

Full-Time <strong>In</strong>dependent Study<br />

Adults in Correctional Facilities<br />

ADA Totals (Sum of A-1 through B-S)<br />

California Department of Education<br />

Attendance Software<br />

2006-6.02 Paae 1 of 2<br />

Fiscal Year: 2006-07<br />

Annual<br />

Certificate Number: 954ABF5D<br />

Elementary High School<br />

A-l 3,342.80<br />

A-2 9,611.01<br />

A-3 8,443.64<br />

A-4 5,224.56<br />

A-5 8,479.66<br />

A-6 280.36<br />

A-7 8.09 172.75<br />

A-8 27.76 24.95<br />

A-9 886.23 411.92<br />

A-10 45.13 49.03<br />

A-11 46.70 19.56<br />

A-12<br />

16.52 13.98<br />

A-13 24.27 13.70<br />

A-14<br />

4.50 5.43<br />

A-15 4.68 1.54<br />

B-1<br />

B-2<br />

B-3<br />

B-4<br />

B-5<br />

B-6 27,685.89<br />

541. 27<br />

44.83<br />

4,890.52<br />

0.00<br />

0.00<br />

14,949.50<br />

7/11/?-007 9.!44L?S 1l,M


County: Alameda<br />

District: Oakland Unified<br />

CDS CODE O~ 6~259<br />

Report.of School District Attendance<br />

Supplemental <strong>In</strong>structional Hours - Summer School /<br />

Before School/ After School/Saturday/<strong>In</strong>tersession<br />

Grades K - 12 Core <strong>In</strong>struction<br />

Grades 7 - 12 Remedial <strong>In</strong>struction<br />

Grades 2 - 9 for Pupils Retained/Recommended<br />

for Retention<br />

Grades 2 - 6 Pupils at Risk of Retention<br />

Grades 2 - 6 Low STAR Score<br />

Total Supplemental Hours (Sum of C-1 through<br />

C-5l<br />

ADA For Students on Full-time <strong>In</strong>dependent Study<br />

<strong>In</strong>cluded in Section A {A-1 through A-7, A-9,<br />

A-12l<br />

ADA for Students Participating in the CALWORKS<br />

Program Pursuant to E.C. 33117.5 <strong>In</strong>cluded in B-1 D-2<br />

ADA for Students Participating in the CALWORKS<br />

program Pursuant to E.C. 33117.5 <strong>In</strong>cluded in B-3 D-3<br />

and B-4<br />

Apprentice Hours Pursuant to Section 3074 of<br />

the Labor Code<br />

Grade 1-12 Cumulative Enrollment Related to<br />

the ADA Reported in Section A (A-2, A-3r A-4r<br />

A-51<br />

Community Day School - Additional Funds (Divisor 70/135/180)<br />

Mandatory Expelled Pupd.Ls - [E.C. 489~5(d) l<br />

5th Hour ADA<br />

6th Hour ADA<br />

All Other Community Day School Pupils<br />

5th Hour ADA<br />

6th Hour ADA<br />

After-School Supervised Attendance<br />

Pupil Hours for 7th Hour<br />

Pupil Hours for 8th Hour<br />

California Department of Education<br />

Attendance Software<br />

2006~6.'02 Page 2 of 2<br />

C-1 0<br />

C-2 0<br />

C-3 0<br />

C-4 0<br />

C-5 0<br />

C-6 0<br />

D-1 28.19<br />

D-4<br />

D-5 28,440<br />

D-6<br />

D-7<br />

D-8<br />

D-9<br />

D-10<br />

D-11<br />

Fiscal Year: 2006-07<br />

Annual<br />

Certificate Number: 954ABF5D<br />

76,209<br />

o<br />

o<br />

76,209<br />

249.43<br />

0.00<br />

11.58<br />

'0<br />

10,042<br />

9.00 7.32<br />

8.92 7.14<br />

7.26 6.27<br />

7.09 5.96<br />

o o<br />

o o


County: Alameda<br />

District: Oakland Unified<br />

CDS CODE 01 61259<br />

Certification<br />

Report of Attendance for Pupils Residing in the District<br />

Fiscal Year: FY 2-006-07<br />

Annual<br />

954ABF5D<br />

I hereby certify that, to the best of my knowledge and belief, this report is true and<br />

correct and all data have been compiled and reported in accordance with state and federal<br />

laws and regulations and the instructions for this report.<br />

School District superintend~t~"""'-""'-c:<br />

'f..E'c., c...~ - F.N. :5J """<br />

Date:<br />

County Superintendent of Schools: Date:<br />

Any inquiries concerning this report should be directed to:<br />

CONTACT NAME David A Lewi s<br />

PHONE (510) 879-8118 *<br />

FAX (510) 879-8836<br />

E-Mail david.lewis@ousd.k12.ca.us<br />

California Department of Education<br />

Attendance Software


County: Alameda<br />

District: Oakland Unified<br />

CDS CODE 01 61259<br />

Report for the Gifted and Talented (GATE) Program<br />

Fiscal Year: 2006-07<br />

Annual<br />

Certificate Number: FEF267D6<br />

The sUbmitting LEA hereby certifies that its GATE plan has been approved by the State<br />

Board of Education and it is participating in the GATE program consistent with the<br />

approved plan<br />

California Department of Education


county: Al~eda<br />

District; Oakland uni.fied<br />

Certification<br />

Fiscal Year: FY 2006-07<br />

Annual<br />

CDS CODE 01 61259<br />

FEF267D6<br />

Report for the Gifted and Talented (GATE) Program<br />

I hereby certify that, to the best of my knowledge and belief, this report is true and<br />

correct and all data have been compiled and reported in accordance with state and federal<br />

laws and regulations and the instructions for this report.<br />

School District superintendent'~<br />

Executive Officer<br />

County Superintendent of Schools: Date:<br />

Any inquiries concerning this ~eport should be directed to:<br />

CONTACT NAME David A Lewis<br />

--------------<br />

PHONE (510) 879-8118 *<br />

FAX (510) 879-8836<br />

E-Mail david.lewis@ousd.k12.ca.us<br />

California Department of Education<br />

Attendance Software<br />

Date, 7=f(..,·~17<br />

Financial Services Division


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

Federal Property: CA003001 Address: PERALTA<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Gladys Jack 1385 12th 5t x Shamesha Anderson 9/27/1994 8<br />

Sharon Aubry 928 Poplar Ct X Akia Aubry-Gordon 8/30/1996 6<br />

COMELITA DAVIS 822 KIRKHAM WAY X Demisha Barker 2113/1990 12<br />

VADAARCHER 834 Kirkham way X Ebony Bames 9/24/2000<br />

Kevin Battle 1114 POPLAR LN X Ke'Ardre BATILE 11/25/1995 7<br />

Elizabeth Wade 12768TH ST X Ednisha Benton 7/5/1997 4<br />

Laure' Bradford-Pineiro 137312th St X Nya Bradford-Logan 8/25/1999 3<br />

COMELITA DAVIS 822 KIRKHAM WAY X Kajanay Brown 2120/1993 9<br />

SHARELLE COLEMAN 815 POPLAR WAY X Michael Brown 5/18/1992 10<br />

FALANEA HENDERSON 1022 MANDELA PKWY #D X La'Shaya Butler 1/14/1992 9<br />

Ericka Taylor 906 Mandela Pkwy X Khallah Byrd 8/14/2000 2<br />

FELICIA CHAPA 137112TH ST X Veronica Chapa 3/14/1990 10<br />

PHALY CHOUN/BO OU 826 MANDELA PKWY #G X Gina Choun 11/11/1989 12<br />

PHALY CHOUN/BOU OU 826 MANDELA PKWY #G X Ronny Choun 10/27/1992 10<br />

This Is to certify that the <strong>In</strong>tonnation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

This is to certify that the infonnation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title<br />

Agency<br />

Title School District<br />

ThiS infonnation is the basis for payment to this school district of federal funds under the Impact Aid Program (Tille Viii of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.<br />

______________________


Federal Property:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003001 Address: PERALTA<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, in Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

JENNIFERLY 1378 10TH ST X Rexile Dayrlt 3/5/2001 1<br />

LESHAWN YOPACK 137110TH ST X Anthony Flournoy 1/211990 10<br />

JIMMIE NELL GADSON 138310TH ST X Andra Gadson 6/30/1991 11<br />

KAREN D MITCHELL 136510TH ST X David Gaspard 3/5/1994 7<br />

CHRISTINE HOLMANI MARIA 814 Poplar Way X Mylea Holdman 9/1/1998 4<br />

VALERIE HALE HOLYFIELD 1108 Mandela Pkwy X Terrence Holyfield 1/29/1993 9<br />

DORETHA GIBSON 1108 MANDELA PKWY #A X Darylnlsha Irvin 8/9/1993 9<br />

Comelita DavislDominlque Irving 822 Kirkham Way<br />

X Zynique Irving 1114/2002 0<br />

CONTESSA M. FRANCO 136712TH ST X Catalina Jackson 4/26/1998 4<br />

Rikeisha Seward 1365 12th St X Jabaree Jenkins 12124/2000 1<br />

RIKEISHIA T. SEWARD 136512TH ST X Joven Jenkins 1/28/1998 4<br />

CONSTANCE JOHNSON 825 UNION ST #L X Henry Johnson 7/30/1994 8<br />

Contessa Mendoza Franco/Jess 1367 12th 51<br />

X Adrian Jones 8/30/2002 0<br />

A1aune Butler 829 POPLAR WAY X Alaunte Keys 8130/1999 3<br />

This is to certify that the information shown under coiumns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Coiumn (1)<br />

on the survey date.<br />

This is to certify that the information shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Titie Agency<br />

Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this schooi district of federal funds under the Impact Aid Program (TItle VIIi of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


FederalProperty:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003001 Address: PERALTA<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

ALAUNE BUTLER 829 POPLAR WAY X Kamryn Keys 12113/2000<br />

Dina Washington 842 POPLAR WAY X Jalen King 3/9/1995 6<br />

Denise Jackson 1103 KIRKHAM LN X Tyler King 8/13/1999 3<br />

CORNELIA HALL 827 Kirkham Way X Adrian Lang 1/18/1997 5<br />

JIE YI LI 845 kirkham way X Haixin Li 7/18/1998 4<br />

JESSICA GATEWOOD L1NYAR 833 Poplar Way X Devin L1nyard 8/2211994 8<br />

JESSICA GATEWOOD 833 Poplar Way X Richard Linyard 1/7/1992 10<br />

Emesto Angel Lopez & Mom En 828 Kirkham Way X Eli Lopez 1112212002 0<br />

Loan Hong Huynh 930 Poplar Ct X Huy Gia Luong 1/10/2001 1<br />

TAMIKA Anderson 924 Mandela Pkwy #H X Armon Marks 4/28/1997 5<br />

Tieisha Jackson 834 KIRKHAM WAY X Keshewn Martin 3/20/1998 3<br />

Jamie Perry 12568TH ST X Monaee MARTIN 8/21/1998 4<br />

Miesha Kelly 901 Poplar Way X Brianna MoCoy 6113/2001 1<br />

Sherr! Williams 1385 10th st X Jermila McElroy 1/24/2001 1<br />

This Is to certify that the infonnatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the parson listed under Column (1)<br />

on the survey date.<br />

This is to certify that the <strong>In</strong>fonnatlon shown under columns (4) and (5)<br />

olthe foregoing sheet(s) is correclfor the person listed under Column (1)<br />

on the survey date.<br />

Signature Data Signature Date<br />

Title Agency Title School District<br />

This infonnatlon Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003001 Address: PERALTA<br />

(1 ) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Shert Williams/Jerome McElroy 1385 10lh SI X Jermya McElroy 5/211996 6<br />

Marisol Melendez 1108 Mandela Pkwy #G X Isis Melendez 1/2211999 3<br />

Felicia & Walter Mira 137112TH ST X Michelle Mira 215/1997 5<br />

Maisha Selmon/Andre Morris 12588th SI X Alalzha Morris 10/6/2001 1<br />

KIM JOHNSON 138610TH ST X Jorrail Manis 10/15/1997 4<br />

Valerte Holyfield 1108 Mandela PKWY X Me'Kaiian Murray 7/5/2002 0<br />

Valerie Holyfield 1108 Mandela Pkwy X Melvin Murray 8/1212000 2<br />

CATHY BROWN/DEBRA 938 Poplar CI X Clifford Nivens 11/2211993 9<br />

SHARON DEMEUSE 837 KIRKHAM WAY X Tori O'brien 3/27/1998 4<br />

SOPHALOK 835 KIRKHAM WAY X David Ok 9/18/1989 12<br />

LYOM 826 MANDELA PKWY #A X AmmaraOm 2114/1994 8<br />

LYOM 826 Mandela Pkwy #A X Rani Om 211/1992 9<br />

JERRY DEAN THOMAS 1370 10TH ST X Joyce Omlniona 1/13/1992 10<br />

Angena <strong>No</strong>rman 825 Union SI X Demonic Palmer 10/612001<br />

This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) is correcllor the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Title Agency Title School District<br />

ThiS information is the basis for payment to this school district of federal funds under the Impact Aid Program (Titie VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CAO03001 Address: PERALTA<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Coiumn (1) Parent/Guardian in Date of Grade<br />

if applicable) ilved on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Mllitary as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

ANGELA NORMAN 825 UNION ST X Duwan Palmer 3/9/1993 8<br />

ANGELA NORMAN 825 UNION ST X Duane Palmer Jr 4/4/1992 9<br />

Decola Pearson 845 Union SI X Jada Pearson 7/8/2000 2<br />

DOREEN HODGES 1006 POPLAR WAY X Michael Peters 4/28/1990 12<br />

Kendra Brewster/ Ali Polk 825 Union St #H X Jalen Polk-Brewster 6/212002 0<br />

TUYET LE 1108 MANDELA PKWY #D X Jenni Quai 2124/2002 0<br />

Kenya Anthony 1105 POPLAR LN X Frenswa Raynor 3/27/1997 4<br />

Jerico RobertsoniKhaliiah Brace 906 Poplar Way X Jaleel Robertson 11110/1999 2<br />

Jerico Robertson Sr/Khalilah Bra 906 Poplar Way X Jerico Robertson Jr 4/16/2002 0<br />

Melinda Ross 826 KIRKHAM WAY X Acacia Ross 2127/1998 4<br />

SamboSao 900 Kirkham Way X Christian Sao 9/14/2002 0<br />

Slacy Richard 825 UNION ST X Angel Searcy 2128/1998 4<br />

CARLEITA COBB 936 POPLAR CT X Quanisha Secrease 7/7/1992 9<br />

DARIKA BATES/EVA SHANNO 844 MANDELA PKWY #D X Shanequia Shannon 10/3/1991 11<br />

This is to certify that the infonmatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

This is to certify that thelnfonmatlon shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) is correclfor the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Tille Agency<br />

Title School District<br />

This <strong>In</strong>fonmatlon Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIIi of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003001 Address: PERALTA<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Shawn Shannon 844 Mandela Pkwy #F X zamani Shannon 12124/1995 6<br />

CLAUDIE ATKINS 915 Union St #A X AUjee Shephard 3/16/1993 8<br />

Denina Denard 834 Poplar Way X Ciara Smith 2fl/2000 2<br />

TOMIKA HENRY 136710TH ST X Erianna Smith 8/8/1996 6<br />

RACQUELFOSTER 825 Union St #F X Hassa Smith 10/2812001 1<br />

JASON SMITHfTANYKA FRYE 1108 Mandela Pkwy X Ja'Lynn Smith 12124/1999 3<br />

Frye TanykalJason Smith 1108 Mandela Pkwy X J'den Smith 5/1212002 0<br />

Denina Denard 834 POPLAR WAY X Leeahna Smith 7/30/1998 4<br />

Felicia Jones 836 Poplar Way X Travelle Smith 11/1211990 9<br />

ANDRE SMITH 841 Poplar Way X Xavier Smith 1/20/1996 5<br />

Marisol Melendez 1108 Mandela Pkwy #G X Desiree Smyth 1/4/1997 5<br />

SOUKCHANHSOURYASAK 828 Poplar Way X Chrtstopher Souryasak 5/24/1993 9<br />

Tieisha Jackson 834 Kirkham way X Marshawn Sylvester 8113/2002 0<br />

Jamie Davis 838 Mandela Pkwy X Jezikiah Talton 213/1999 3<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) end (5)<br />

ofthe foregoing sheet(s) is correcttor the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Title Agency TItle School District<br />

This <strong>In</strong>formation is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Federal Property:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003001 Address: PERALTA<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

Lashon Tyson 840 POPLAR WAY X<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Daejuanay THOMAS 1/4/1995 7<br />

REGINA THOMAS 840 KIRKHAM WAY X James Thomas 3/19/1990 10<br />

Cathy Brown/Keith Thomas 938 Poplar CI X Marontay Thomas 7/31/1991 11<br />

CATHY BROWN 938 Poplar CI X Marquis Thomas 7/26/1990 12<br />

JOY TRENT 1373 10lh SI X<br />

Jacari Trenl-Pontoon 3/23/1997 4<br />

MONACHA 136610TH ST X Nathan Tsui 12111/1997 4<br />

Latisha Bryant 940 Poplar Ct X TaijahTumer 9/13/2000 2<br />

Slacy Ricardl Kevin Valentine 825 Union 51 X<br />

Dy'lon Valentine 1/2112002 0<br />

Doretha Gibson 1108 MANDELA PKWY #A X Michael Warrick 9/14/1990 10<br />

Agnes Warrick 1108 Mandela Pkwy #A X<br />

keisha honeywood 826 Mandela Pkwy #e X<br />

Roger Warrick 10/10/1990 10<br />

Dwayne Washington 8/21/2000 2<br />

BOBBIE MCCULLOUGH 824 Poplar Way X Kimiesha Whiteside 1211211990 10<br />

Dorothy Williams 1284 8th 51 X<br />

Cordell Williams 4/17/2001 1<br />

GAIL SMITH 1108 POPLAR LN X Rondrea Williams 1/2211992 9<br />

This Is to certify that the information shown under columns (4) and (5)<br />

oflhe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature<br />

Tille<br />

Agency<br />

This is to certify that the information shown under columns (4) and (5)<br />

oflhe foregoing sheet(s) is conrect for the person listed under Column (1)<br />

on the survey date.<br />

Title<br />

Date<br />

School District<br />

This <strong>In</strong>formation is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


_


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003001 Address: PERALTA<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

ParentlGuardian's ParentlGuardlan's Branch of Service ParentlGuardian ParentlGuardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) ParentlGuardlan <strong>In</strong> Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Dorothy Williams 1264 8th St X Selena Williams 11/26/1995 6<br />

Latonya Dean 825 UNION ST #K X Monique WILSON 11/1011997 5<br />

Tyisha Wri9ht 914 Mandeia Pkwy X DESHAWN WRIGHT 11/15/1998 3<br />

TILLIS WRIGHT, TYISHA M. 914 Mandela Pkwy X JORDAN WRIGHT 7/10/2000 2<br />

Tyisha Danzy 1372101h St X Tyllea Antoine' Young 9/24/2000 3<br />

Number Students At This Property 103<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature<br />

Date<br />

Title Agency Title<br />

School District<br />

This information Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for thIs school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003002 Address: CAMPBELL VILLAGE<br />

(1) (2) (3) (4) (S) (6) (7) (S)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

MONICA PARKS 883 Campbell Village Ct X Keonre Belton 12/1/1992 9<br />

Rosalyn Fountain 883 campbell St X Samuel Briggs 3115/2001<br />

ROSALYN FOUNTAIN 883 Campbell St X Tacherla Briggs 9/19/1996 5<br />

JOYCE ROBERTSON 16968TH ST X Tiara Brown 1/9/1999 3<br />

Sel Butlerl Nicole Doman 889 Campbell ST X Sel Butler Jr. 7/1311996 7<br />

LAKESHIA THOMAS 866 WILLOW ST X Elijah Carey 1/22/1998 4<br />

Patricia Austin/Ms. S. Lath 945 campbell St X Passion Carr 7/2611990 10<br />

NATASHA COOPER 890WlllowSt X Zachariah Cooper 5/4/1994 8<br />

HAMMOLEKETH RAMSEY 872WiliowSt X Danny Davis 7/10/1998 3<br />

ROBBIE MANSFIELD 865 CAMPBELL VILLAGE CT X ZIARA DeBOSE 5/28/2001 1<br />

CARLA GREEN 896 CAMPBELL VILLAGE CT X FRIZZELL DEVERS V 3/5/2001 1<br />

MONIQUE COLE 901 Campbell Village CI X James Evans 6/24/1991 11<br />

EmestClark 928 Willow St X Tyesha Evans 11/23/1990 10<br />

Melica Johnson 900WillowSt X Nashara Fountaine 5/4/2000 2<br />

This is to certify that the infonnation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

This is to certify that the infonnalion shown under columns (4) and (5)<br />

olthe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title<br />

Agency<br />

Title<br />

School District<br />

This infonnation is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Signature<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007,<br />

FederalProperty: CA003002 Address: CAMPBELL VILLAGE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

ERICKA PARKER 801 CAMPBELL ST X Mikell Gentry 5/26/1997 4<br />

Katrina Williams 888WillowSt X Kierra Griffin 3/4/1999 3<br />

SHWANA AMMONS 860 WILLOW ST X Keara Grimes 4n11990 11<br />

MONICA MCWILLIAMS-PARKS 883 campbell Village Ct X James Hall Jr 10/3/1997 5<br />

CATHERINE LAVON 801 CAMPBELL ST #E X Giana Hamilton 8/8/1994 8<br />

NINA AUSTIN 945 CAMPBELL ST X Andrea Harris 7/9/1991 11<br />

TAMIDAVIS 897 Campbell St X Jhordan Hollingsworth 2114/1993 9<br />

Rynika Hodge 903 Campbell Village Ct X Davion Johnson 6/28/2000 1<br />

Natasha Cooper 890 Willow St X Emani Johnson 9/13/2001 1<br />

SHERECE HODGEIRynika Hod 903 Campbell Village Ct X Ernonl Johnson 7/29/1999 2<br />

ebony staphaney 166710th St X zyaire knlghten 10/14/2001 1<br />

REGINA AUSTIN 945 CAMPBELL ST X Shanlka Latham 10/211991 10<br />

SHWANA AMMONS 860 WILLOW ST X Bryon livingston 12124/1992 9<br />

Anytra Henderson 912WillowSt X Tyana Mitchell 211211989 12<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Title<br />

Date Signature<br />

Agency<br />

This Is to certify that the information shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Title<br />

Date<br />

School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school distrIct to receive funds based on this <strong>In</strong>formation.


FederalProperty:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003002 Address: CAMPBELL VILLAGE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Shwana Ammons 860WillowSt X Diamond Myles 1216/1999 2<br />

STEPHANIE THOMAS 871 Campbell SI X Leilani <strong>No</strong>el 4/6/2001 1<br />

SHERRY SIMS 901 CAMPBELL ST X Marcus O'Neal 9/5/1999 3<br />

HAZEL DIXON 915 campbell Village Ct X <strong>No</strong>risha Price 2118/1999 3<br />

POEV THOU & SATH PROM 1667 10TH ST #E X Shirley Prom 9/1211995 7<br />

Wanda Reedffreya Reed 895 campbell SI X Cuevona Reed 4/2212001 1<br />

NAKIMA WALKER 915 CAMPBELL ST X Kehinde Riley 1/211996 6<br />

THELMA ROSS 824 WILLOW ST #B X Sherry Ross 7/13/1999 3<br />

LA TREASHA MCCOY 884 Willow SI X Malik Salam 3/5/1994 9<br />

RANDY HARVEY 1692 8TH ST X Kilomokie Stewart 8117/1998 3<br />

JANICE C. TOWNSEND 884 Campbell Village Cl X AmaniTownsend 9/14/1999 2<br />

OULIMATASY 879 campbell SI X Maguell Wade 7/27/1995 5<br />

Michele Meadows 878 Campbell Village Ct X Andrew Williams 6/26/1989 12<br />

KELLYE MOORE 865 Campbell SI X Kenisha Williams 7/11/1990 12<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correcllor the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

Date<br />

Agency<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (S)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

Date<br />

School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


----~---------


Federal Property:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003002 Address: CAMPBELL VILLAGE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Miracle Turner 877 Campbell Village Ct X Lailani Williams 7/8/2002 0<br />

MICHELE MEADOWS 878 CAMPBELL VILLAGE CT X Mackenzie Williams 121711997 4<br />

Sonya Brtdges 1697 10lh St X Vivicka Williams 2115/2000 2<br />

TALISHIA WARD 914 WILLOW ST X<br />

Date Signature Date<br />

DAVID WOOLRIDGE 6/4/2002 0<br />

Talisha Ward 914 WiliowSl X Mazionna Woolridge 9/19/1993 9<br />

SHEILA PHILLIPS 859 CAMPBELL ST X Lamont Young 10/13/1994 8<br />

Number Students At This Property 48<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

Agency<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Title<br />

School District<br />

This <strong>In</strong>formation is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003003 Address: LOCKWOOD GARDENS<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Christine E. Young 1124 65th Ave #C X Milani Alexander 7/30/1994 8<br />

MISHA HUNTERIDELAHOUSS 1201 65th Ave #A X Edward Bailey 4/8/1994 8<br />

Gregory Bailey 1031 66th Ave X Jordan Bailey 1215/1998 3<br />

Joyce Leeks 1263 65th Ave X Jordan Barnes 1/19/2001 1<br />

Rhonda Howard 1125 65th Ave #B X Brandy Bowie 9/16/2002 0<br />

Khamisi Jackson 6503 Fenham St #C X Kiante Brown 5/6/2000 2<br />

Trineka Marie Brown 1259 66th Ave X Kinasha Brown 3/28/1995 7<br />

Khamisi Jackson 6503 Fenham St #C X Klonnie Brown 5/6/2000 2<br />

Gelenda Brown 1341 66th Ave X Zaquel Burris 12110/1999 2<br />

Margie Rollerson 1221 66th Ave X Saudra Buyard 8/15/2001 1<br />

Zhengqiang Cai 1219 65th Ave #A X Vingtong Cai 6/19/1999 3<br />

SOPHIE STOLAROFF 1363 66th Ave X Marcus Carroll 6111/1990 12<br />

Trineta M Brown 1259 66th Ave X Imani Cherry 4/16/1998 4<br />

LATRINA DIXON 6507 Eastlawn st X Key'Maurie Clark 11/13/1996 5<br />

This is to certify that the infonnation shown under columns (4) and (5) This Is to certify that the <strong>In</strong>fonnatlon shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correct for the person listed under Column (1) ofthe foregoing sheet(s) Is correcltor the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title<br />

School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


-----------------~~~~~~~~~-~


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003003 Address: LOCKWOOD GARDENS<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

PATRICIA JOHNSON 1363 66th Ave X Mark Collins 12123/1990 10<br />

Melita Jenkins 1149 66th Ave X Elena Cook 6/28/2002 0<br />

Rachel Hicks 1320 65th Ave X Selena Cordaway 11/27/1998 3<br />

Miranda Achie 1205 65th Ave X Keyana Crisp 12110/1992 9<br />

TAMMY WILLIAMS 1253 65TH AVE #H X Hassan Darrah 12130/1992 9<br />

Mack, StartaiDennis, Kelvin 1234 65th Ave X Kelviauna Dennis 8/1/2002 0<br />

MICHELLE CARTHON & VELV 1316 65TH AVE X Denne' Dickson 1/13/1996 6<br />

MICHELLE CARTHON 1316 65th Ave X Dontae Dickson 9/3/2001 1<br />

CARMEN L.MILLER 1136 65th Ave #0 X Iyala Edmond 8/25/1999 2<br />

GLORIA RICHARD 1252 65th Ave X Omari Embrey 7/30/1998 3<br />

Tomisha Wade 1110 65th AVE X Jordan Emmanuel 6/8/2002 0<br />

KESHIA EVANS 1125 65th Ave X Da'Janae Evans 4/21/1992 9<br />

KEISHA EVANS/ALFREDIA 1125 65th Ave X Keshla Evans 4/21/1992 9<br />

Shelonda Evans 1356 65th Ave X Vaughn Evans-Chandler 8/19/1998 4<br />

This is to certify that the infonnation shown under columns (4) and (5) This is to certify that the infonnatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1) olthe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title School District<br />

This <strong>In</strong>tonnation is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003003 Address: LOCKWOOD GARDENS<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

christina marie shavers 1333 66th Ave X D'ovyon Figg 8/2212001 1<br />

Monique Bell 6531 EasUawnSI X Jason Fluker 1110/1992 10<br />

GLENN FULLER 1234 65th Ave X De'Janee Kiar Fuller 10/16/1989 9<br />

Patricia Gates 1262 65th Ave #B X Jerrell Gates 10/28/1999 2<br />

Dansheeka Glaser 1107 65th Ave X Jayla Glaser 8/3/2002 0<br />

Ruby Habeebullah 1325 65th Ave X Alonzo Grays 5/30/2001 1<br />

LAYLAGREEN 1225 66th Ave X Rachel Green 5/24/1991 11<br />

SHELIA L. SMITH 1201 65TH AVE #C X Stardazia Hailey 4/7/1999 3<br />

VALERIE MILTON 1263 65TH AVE X Latifa Hairston 5/2911990 11<br />

AUTONYALEE 1163 65TH AVE #A X Tiyanna Harris 7/1611992 9<br />

VELMA MCDANIEL & NOBLE H 6503 FENHAM ST #H X <strong>No</strong>ble Harris IV 6/26/1994 8<br />

MALIKAIMARION JACKSON 1119 65th Ave X Javaughnie Heartfield 7/13/1992 10<br />

CYNTHIA WILLIAMS 1229 65TH AVE #H X Ashley Hightower 8111/1994 7<br />

DONALDNELMA RICHARDSO 1306 65TH AVE X ShanUerraHill 12131/1995 6<br />

This is to certify that the <strong>In</strong>fonnation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

This is to certify that the infonnation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Agency<br />

Title<br />

School District<br />

This infonnation is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


FederalProperty:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

CA003003 Address: LOCKWOOD GARDENS<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Deandre Williams 1229 65th Ave #G X Idaeja Hills-Williams 3114/2002 0<br />

DEANDRE L.WILLIAMS 1229 65TH AVE #G X Teandre Hills-Williams 11/9/1998 4<br />

Rhonda Miller/David Holmes 1260 65TH AVE X Cora Holmes 4/20/1990 12<br />

LAQUANDA GREEN 1305 65TH AVE X Marquise Holmes 9/14/1995 7<br />

MALIKA HEARTFEILD & L10NE 1119 65TH AVE<br />

X Deoote' Holoman 4/511996 6<br />

GENNICE ELLISON 6511 Fenham St #G X Kevin Hope 12120/1992 9<br />

DIEUHUA 113565thAve#H X MiHua 10m1993 9<br />

DUCHUA 1228 65th Ave #C X Phat Hua 5/1711992 10<br />

DIEUHUA 1135 65th Ave #H X Phuong Hua 4/23/1995 7<br />

Latasha Gray 110565thAve#D X Desirae Ibarra 3/4/2000 2<br />

GELENDA BROWN 1341 66th Ave X Juan Ignacio 8/27/1994 8<br />

Shakrita Harris/Cedric Irving 1325 65TH AVE #F X cedric Irving 11/14/1998 3<br />

Shakrita Harris 1325 65th Ave #F X Samuael Irving 9/15/2001 1<br />

KHONSAVANH SOUVANNARA 1246 65TH AVE<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

Date<br />

Agency<br />

X Nate Javius 2110/1995 7<br />

This is to certify that the information shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correclfor the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

Date<br />

School District<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


FederalProperty:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003003 Address: LOCKWOOD GARDENS<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

Rachel Tijerina 1135 65th Ave #G X<br />

ERIC JOHNSON SR. 1103 65th Ave X<br />

Chartotte Lynn 1254 65th Ave X<br />

ERIC/NADINE JOHNSON<br />

1103 65th Ave #C<br />

PATRICIA JOHNSON 1222 65TH AVE X<br />

Nadine Allen/Eric Johnson 110365thAve#C X<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

X<br />

AU9us<strong>tJ</strong>ohnson 5/24/1997 5<br />

Eric Johnson 217/1993 9<br />

Jahns Johnson 2115/2000 2<br />

Krystal Johnson 10/13/1991 9<br />

Love Johnson 8/29/1991 9<br />

Nadine Johnson 11/27/1995 6<br />

MONIQUE HUNTER 1201 65TH AVE #F X Jae'La Jones 11/10/1994 8<br />

FRANCESCA DAVIS 1101 65th Ave #G X<br />

Stephanie Pierce 1257 66th Ave X<br />

Stephanie Pierce & Patrick Kelly 1257 66th Ave<br />

Jacqueline DorseyNance Stewe 1124 65th Ave #0<br />

Marcia Hollie 1228 65th Ave X<br />

CATRINASIMS<br />

1225 66th Ave<br />

APRIL LEWIS 1332 66TH AVE X<br />

This Is to certify that the <strong>In</strong>fonnatlon shown under columns (4) and (5)<br />

of the fore90in9 sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature<br />

Title<br />

Agency<br />

Sidney Jones 11/15/1990 10<br />

Ashantt Kelly 3/21/2001 1<br />

X ImanJKelly 8/25/1998 3<br />

X<br />

X<br />

Ja'Kel Keys 9/23/2001 1<br />

Gerrah Lampkin 3/11/1994 8<br />

Deijunae Lebrane 8/16/1994 8<br />

Mizahni Lewis 4/1711999 3<br />

This Is to certify that the infonnatlon shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correcllor the person listed under Column (1)<br />

on the survey date.<br />

Title<br />

Date<br />

School District<br />

This <strong>In</strong>fonnation Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CAO03003 Address: LOCKWOOD GARDENS<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of PUpil Living With PUpil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, in Column (1) <strong>In</strong> Coiumn (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

YAN LI 1253 65th Ave #D X Mei Yun Li 4/15/1994 8<br />

YANLI 1253 65th Ave #D X Qlyun LI 4/22/1996 6<br />

STARLAMACK 1234 65TH AVE X Charles Mack 1/15/1999 3<br />

STARLAMACK 1234 65TH AVE X Devaunte Mack 10/1611993 8<br />

DERRICK MAPP 1262 65TH AVE #C X Onyx Mapp-Childs 3/2/1993 9<br />

Drusilla Zeno 1315 65th Ave #H X Dajohn McConnick 71712000 2<br />

Marcilla labice Marable 6506 Fenham St X Tzion Mcelroy 6/23/2001<br />

SAVORNMEY 1228 65TH AVE #F X Sroeun Jr Mey 6/27/1995 7<br />

KIM KING 1334 65TH AVE X Kendale D'Ang Molden 12/31/1995 6<br />

QUINTINA BONDS 1101 65TH AVE #B X Lou-Zhane Montgomery 7/13/2001 1<br />

KIML. WALLS 1219 65TH AVE #B X Disserae Moore 5/20/1990 12<br />

Dywan Nelson 1229 65th Ave #B X Devante Nelson 111711996 5<br />

Lanelta Figg 1163 65TH AVE #C X Quintin Nelson 5/17/1997 5<br />

Shamika Newman 6520 Eastlawn St X Tayshawn Newman 10/20/2001 1<br />

This Is to certify that the <strong>In</strong>formetlon shown under columns (4) and (5) This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correctfor the person listed under Column (1) of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature Date Signature Date<br />

Title<br />

Agency Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the impact Aid Program (TItle Viii of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


FederalProperty:<br />

Chi Tran<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

(1) (2) (3) (4) (5) (6) (7) (S)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil'S Pupil'S<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

Lam Nguyen<br />

CA003003 Address:<br />

1315 65th Ave #0<br />

1253 65th Ave #C<br />

Phuong Thi NguyenlLam Phi Ng 1253 65th Ave #C<br />

LYNNE NICOLS<br />

Jennifer Outley<br />

JUNE ALLISON<br />

Rachel Tijerino<br />

Ikishna Love<br />

April Patrick<br />

Sherry Smith<br />

1340 65th Ave<br />

1219 65th Ave #H<br />

116365THAVE#G<br />

1135 65th Ave<br />

1218 65th Ave #C<br />

6503 Fenham St<br />

1218 65th Ave #H<br />

Adrienne Roy 1258 65th Ave<br />

Malika Heartfield<br />

111965thAve<br />

Hasanni Richard/Monique Bell 6531 Eastlawn st<br />

STARLAMACK<br />

1234 65TH AVE<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

Date<br />

Agency<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

X<br />

X<br />

X<br />

X<br />

X<br />

X<br />

X<br />

X<br />

Signature<br />

LOCKWOOD GARDENS<br />

Kevin Nguyen 7/20/2000 2<br />

Linda Nguyen 1/512001 1<br />

Lisa Nguyen 11/5/2002 0<br />

Swauva Nichols 1211011991 9<br />

Johnathan Outley 4/26/2002 0<br />

Juvonte Owens 3/16/1991 10<br />

Kendell Owens 1212011999 2<br />

Christopher Patrick 11/30/2002 0<br />

'X Xaire Patrick 6/5/2000 2<br />

X<br />

X<br />

X<br />

X<br />

X<br />

Paula Patterson 12131/1989 12<br />

Oontrel Powell 6/11/2002 0<br />

Jackeerah Ray 10/21/2002 0<br />

Jalyn Richard 8/8/2000 2<br />

Dashawn Rico 8/3/1992 9<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Title<br />

Date<br />

School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003003 Address: LOCKWOOD GARDENS<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, in Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

SAMUELA BLACKSHER 1103 65th Ave #A X Andre Ridge 2113/1992 9<br />

SAMUELA JEAN BLACKSHER 110365thAve#A X Semaj Ridge 6/10/1993 8<br />

LATRINA RIVERAIALQUILINO 6507 EASTLAWN ST X BRIONA RIVERA 6/8/2001 1<br />

REMOUS TOOMBS 113565thAve#A X Jon Rodgers 3/9/1992 10<br />

CLAUDIA RODRIGUEZ 1219 65th Ave #D X Angelina Rodriguez 7/24/1996 6<br />

Claudia Mendez 1219 65th Ave #D X Pedro Rodriguez 11/17/1992 10<br />

Angelina Romero 1109 65th Ave X Ana Romero 10/10/1995 7<br />

Angelina Romero 1109 65TH AVE X EDGAR ROMERO 1/29/2002 0<br />

Angelina Romero 1109 65th Ave X Eduardo Romero 212612000 2<br />

ANGELINA ROMERO 1109 65th ave X Jesus Romero-Gil 5/28/1994 8<br />

June Allison/Prophet Sar 116365thAve#G X Jakil Sarhim 6/30/1997 5<br />

Ashaki Thomas 1262 65th Ave #G X Akashi Soott 1/6/1993 9<br />

ELEANOR EDMONDS 6503 Fenham St #A X Jonathan Soott 12126/1991 9<br />

CHRISTINA SHAVERS 1333 66TH AVE X Darien Sensabaugh 8/18/1994 8<br />

This is to certify that the information shown under columns (4) and (5) This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1) ofthe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature<br />

Date Signature Date<br />

Title Agency Title<br />

School District<br />

This <strong>In</strong>formation is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Federal Property:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003003 Address: LOCKWOOD GARDENS<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, in Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

DANA SIBLEY 1262 65TH AVE #A X Trlnese Sibley 5/10/1994 8<br />

Starla Mack 1234 65th Ave X Juanyae Simonton 12/17/1999 2<br />

CARMEN MILLER 113665THAVE#D X HEAVENLY SIMPSON 5/9/2002 0<br />

Felicia Brown 1312 65TH AVE X Latiana Sims 11/7/1997 4<br />

FELICIA BROWN 1312 65TH AVE X TatianaSims 11n/1997 4<br />

SANDRA ROY & ANTHONY SM 1258 65TH AVE X Gianna Smith 10/11/1995 6<br />

JUMANNE SMITH 1219 65th Ave #G X Kemanne Smith 11/15/1995 7<br />

Marcus Smith ISusan Spears 1369 66th Ave X Marcus Smith 5/22/1992 9<br />

SUSAN SPEARS/MARCUS 1369 65TH AVE X Steven Smith 9/1/1993 7<br />

Parlsha Hodge 1105 65th Ave X Caprisha Stevenson 12/1711999 2<br />

Colette Walker 6511 Fenham St #F X Champala Thomas 3/23/1993 9<br />

Patrice Gastile 6511 Fenham St #B X Da'Shod Thompson 5/14/2000 2<br />

CHI MY TRAN & NHUT CONG 1315 65TH AVE #0 X Linda Tran 5/5/1994 8<br />

CHITRAN 1315 65TH AVE #D X Tran Tran 2/4/1993 9<br />

This Is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


FederalProperty:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003003 Address: LOCKWOOD GARDENS<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

Monica Rice-Walker<br />

Monica Rice-Walker<br />

1229 65th Ave #D<br />

1229 65th Ave #D<br />

Jameelah Smith 1201 65th Ave #D X<br />

VELMA MARIE RICHARDSON 1306 65TH AVE X<br />

Marcia Hollie<br />

1228 65th ave<br />

LISA BRADY 1252 65TH AVE #D X<br />

VIRGINIA ALLEN 1157 65TH AVE X<br />

ROCHELL JAMERSON<br />

1252 65th Ave #A<br />

VIGINIA ALLEN/JOSEPH WILLI 1157 65th Ave<br />

VIRGINIA ALLEN<br />

Joyce Leeks<br />

Quintina Bonds' Kelly<br />

1157 65th Ave<br />

1263 65th Ave #C<br />

1101 65th Ave<br />

CARMEN MILLER 1136 65th Ave #D X<br />

Tywana Titus/Mario Woodard 6503 Fenham St #F X<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

Date<br />

Agency<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

X<br />

X<br />

X<br />

X<br />

X<br />

X<br />

X<br />

X<br />

Benicia Walker 10/10/2000 1<br />

Bennie Walker 12115/1998 4<br />

Jawon Wallace 10/1212000 2<br />

Tameisha Ware 6/15/1993 8<br />

Shemirah Waters 3/6/2001 0<br />

Michelle Watts 9/9/1995 7<br />

Jonetta Williams 6/11/1995 7<br />

Klanie Williams 5/25/1999 3<br />

La Gina Williams 4/6/1992 10<br />

Lajoyce WIlliams 3/8/1991 11<br />

Randy Williams 12126/1993 8<br />

Shonesha Wilson 8129/2000 2<br />

T'evinWilson 11/16/1991 10<br />

Daven Woodard 216/2002 0<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

Date<br />

School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


--------------------


Federal Property:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003003 Address:<br />

LOCKWOOD GARDENS<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

Tiffany Miles/James Worthington 1163 65th Ave #F<br />

FELICIA BROWN 1312 65TH AVE<br />

GUO NING YU 6511 Fenham St #A<br />

Number Students At This Property 143<br />

This is to certify that the <strong>In</strong>fonnation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

Date<br />

Agency<br />

YES<br />

x<br />

I NO YES I NO<br />

X<br />

X<br />

Jacion Worthington<br />

Christian Wylder<br />

CindyYee<br />

This Is to certify that thelnfonnatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

Date<br />

School District<br />

3/212001<br />

5m1995<br />

11/27/1996<br />

This infonnatlon Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This fonn must be signed and dated for this school district to receive funds based on this <strong>In</strong>fonnatlon.<br />

1<br />

7<br />

6


FederalProperty:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

CA003008A Address: 1110 64TH AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil LIving With, Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

STEPHANIE WILLIAMSON 6403 FENHAM ST #59<br />

Latonia Thomas<br />

6403 Fenham St #26<br />

Number Students At This Properly 2<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title Agency<br />

Date Signature<br />

YES I NO YES I NO<br />

x<br />

x<br />

Kyndal Lakey<br />

Jeanna Thomas<br />

This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Title<br />

Date<br />

School District<br />

This information Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

this form must be signed and dated for this school district to receive funds based on this information.<br />

11/1/1993<br />

3/9/1994<br />

8<br />

7


Federal Property:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003008D Address: TASSAFARONGA<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES -I NO YES I NO<br />

Telieia Harris & Antwaan Carroll 8300 G St#A X A1iaja Anderson 4/212001 1<br />

Pamela Hemmingway/Curtis An 945 84th Ave #0 X Arnadi Angelo 4/4/2002 0<br />

Patrice Garrett 938 84TH AVE #F X Armand Belvin 12128/1997 4<br />

Hansberry Regina 935 85th Ave #0 X Alan Brownly 121111995 4<br />

Vanisha Dixon 935 85th Ave #C X Shanika Carter 11/29/1991 10<br />

SOPHALCHAN 8310 G ST#E X David Chan 11/8/1990 12<br />

Angela Chappill 930 84th Ave #E X Danteneh Chappill 8/19/2002 0<br />

TANYA MC CLAIN 930 84TH AVE #A X Derrall Crummie 5/1211989 11<br />

TANYA MC CLAIN 930 84TH AVE #A X Trival Crummie 11/5/1990 11<br />

Sophal Chan 8310 G St#E X Kaylonl Dethvongsa 71712000 2<br />

PEARLIE RUCKER 926 84TH AVE #B X Ricky Flowers 3/15/1995 6<br />

KIMBERLY CHUNN 938 84TH AVE #C X Azuri Freeman 4/1212002 0<br />

CASSANDRA GAAR 918 84TH AVE #C X Adam Gobar 818/1997 5<br />

SHARONDA GREEN 947 84th Ave #C X Emonee Green 7/23/1998 4<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

Date<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Agency Title School District<br />

This <strong>In</strong>formation is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.<br />

Date


Federal Properly:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003008D Address:<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, in Column (1) in Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

DELISHIA WILLS 938 84TH AVE #A X<br />

SHARON WELCH<br />

ROTRINDA WALLS<br />

915 84th Ave #A<br />

947 84th Ave #A<br />

RyniquekaiJefferey Hodge 917 84th Ave #E X<br />

ARTIS JOHNSON & LATONYA 917 84TH AVE #D X<br />

Janelle Murphy<br />

ArIIs Johnson/Elizabeth Allen<br />

926 84th Ave #c<br />

917 84th Ave #D<br />

DARRICK KENNEDY 918 84TH AVE #D X<br />

Lanesa Franklin 945 84th Ave #E X<br />

Franklin, Lanesa 945 84th Ave #E<br />

CASSAUNDRA GAAR 918 84TH AVE #C X<br />

EVELYN STEPHENS<br />

YOEUNGMEAS<br />

YOEUNG MEAS<br />

8300G ST#B<br />

8310 G ST#A<br />

8310 G ST#A<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

Date<br />

Agency<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

X<br />

X<br />

X<br />

X<br />

X<br />

X<br />

X<br />

X<br />

Signature<br />

TASSAFARONGA<br />

Akaysha Grogans 11/6/1991 10<br />

Ameriah Hayes 5/15/1992 10<br />

Kanesha Herron 5/17/1991 10<br />

Jarrett Hodge 81812000 2<br />

Artisha Johnson 4/1311995 7<br />

Farrarri Johnson 3/17/2000 2<br />

Mercedes Johnson 10/1211992 9<br />

Rakheem Kennedy 4/1911996 6<br />

Dannisha Lacey 3/2211996 6<br />

Davon Lacey 6/20/1997 5<br />

Ashley Lon9 11/311991 10<br />

Fredniesha Me Raven 1/211991 11<br />

RadyMeas 2124/1990 11<br />

Sokphany Meas 212211992 10<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Title<br />

Date<br />

School District<br />

This information Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Federal Property:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003008D Address: TASSAFARONGA<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, in Column (1) in Coiumn (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

FATINMAAIKENS<br />

PEARLEAN LEGGINS/Gwen Hi<br />

ANDREA HAYWOOD<br />

8300 G St#6<br />

915 84TH AVE #6<br />

926 84TH AVE #E<br />

VIRGILIA GAYLORD & JAMES 8300G ST#E<br />

REGINNSHARN1CE<br />

935 85th Ave #0<br />

Soeub Say 926 84TH AVE #A X<br />

TANYA MCCLAIN MICHAEL<br />

Shalena D. Edwards<br />

VANISHA A. DIXON<br />

VANISHA DIXON<br />

DELISH1AVALLIER<br />

SONYA VERDINE<br />

VICKIE GOINS<br />

AISHANALLS<br />

930 84TH AVE #A<br />

941 84th Ave<br />

935 85TH AVE #C<br />

935 85TH AVE #C<br />

938 84TH AVE #A<br />

935 85TH AVE #E<br />

8300G ST#E<br />

938 84TH AVE #0<br />

This Is to certify that the information shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) is correctfor the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

Date<br />

Agency<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

X<br />

X<br />

X<br />

X<br />

X<br />

X<br />

X<br />

X<br />

X<br />

X<br />

X<br />

X<br />

X<br />

Signature<br />

KAMAR NELSON 10/25/2002 0<br />

Lakisha Peoples 5/6/1993 8<br />

Kenneth Perry 6/21/1994 8<br />

Jessica Posey 11/15/1993 8<br />

Anthony Snead 10/1411993 8<br />

Amanda So 11/28/2000 2<br />

De'Jomae Thomas 5/22/1995 7<br />

Tyrone Thompson Jr 8/16/1999 3<br />

Casey Tumer 10/11/1994 6<br />

Sir William Tumer 10/29/1997 4<br />

Chlishay Vallier 9/2/1994 8<br />

Sultanah Waqia 111712000 2<br />

Joshua Wheelock 1/10/1992 10<br />

Ayana While 6/12/1996 6<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Title<br />

Date<br />

School District<br />

This <strong>In</strong>formation is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Federal Property:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003008D Address:<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

Fatima Aikens 8300 G St#B<br />

EVELYN STEPHENS 8300 GST#B<br />

Delishia Wills 938 84TH Ave #A<br />

SHARON WELCH 915 84th Ave #a<br />

Aisha Nalls 938 84TH AVE #D<br />

VERNETTA WOODS 938 84TH AVE #E<br />

Number Students At This Property<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the parson listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

Date<br />

Agency<br />

48<br />

YES I NO YES I NO<br />

TASSAFARONGA<br />

X Dajah White 5/14/2001<br />

X Mikiesha Williams 2/16/1994 7<br />

X TajaeWilis 5/2/1996 5<br />

X Cortez Wilson 9/12/1995 7<br />

X Mack Woodfox 12/25/1997 4<br />

X Zaria Woods 6/5/1998 4<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

Date<br />

School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact AId Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


---------------


Federal Property:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003013 Address:<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

EUGENIA JACKSON 727 37TH ST #6<br />

EUGENIA JACKSON 727 37th St #6<br />

LATRENDA SMITH 522 32ND ST #4<br />

LATRICIA KING 727 37TH ST #5<br />

Eugenia Jackson 727 37TH ST #6<br />

Jackson ,Eugenia 727 37TH ST #6<br />

latrice Johnson 727 37th St #4<br />

Number Students At This Property<br />

This is to certify that the information shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

Date<br />

Agency<br />

7<br />

72737TH ST<br />

YES I NO YES I NO<br />

X Amika Barriga 11113/1989 11<br />

X Arnisha Barriga 11113/1989 11<br />

X Malika Cade 3/1011991 10<br />

X Devin Hooten 1/1911990 11<br />

X Harry lawrence 211611998 4<br />

X Horatio Lawrence 11117/2001 1<br />

X Christian Rhodes 11/211996 4<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

Date<br />

School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Federal Property:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003014 Address: 2003 E 25TH ST<br />

(1) (2) (3) (4) (5) (6) . (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES T NO<br />

NICOLE MCCLELLAN 2003 E 25TH ST #A X Keondralan Bennett 3/30/1992 10<br />

ANITA MILES 2711 26TH AVE #D X Diamond Blackwell 7/19/1998 4<br />

Ericka Stephens 8021 Plymouth St #D X Daven Carroll 1211/2000 2<br />

DAWN CARTER 9427 PLYMOUTH ST #A X DARNELL CARTER JR 5/31/2001 1<br />

ROSE EDWARDS 2711 26TH AVE #C X Naurenee Edwards 7/14/1990 12<br />

dawn russell 9427 plymouth st #a X Antwaney Harris 4/5/1999 2<br />

Rena Robertson 9427 Plymouth St #A X Patricia Hawkins 12111/1991 10<br />

Hunt, Lilliannia 8021 Plymouth St #A X Reginald Hunt 1214/2001 0<br />

Anita Miles 2711 26th Ave #D X Brejanay Nelson 9/2211999 3<br />

LONG KIM TANG 2003 E 25TH ST #C X Derrick Ourm 5/2211997 5<br />

Holly Pen 2003 E 25th St #C X Daren Tang 4/11/2000 2<br />

Holly Pen 2003 E 25th St #C X Douglas Tang 9/29/2001 0<br />

DONNA MONSON 9427 PLYMOUTH ST #C X Jasmine Ware 9/27/1994 8<br />

ANITRA MILES 2711 26th AVE #D X Marquise Weaver 11/11/1992 10<br />

This is to certify that the infonnatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

Date<br />

Agency<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correctfor the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

Date<br />

School District<br />

This infonnation is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Federal Property:<br />

Signature<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003014 Address: 2003 E 25TH ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

Number Students At This Property<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

oflhe foregoing sheet(s) Is correctfor the person listed under Column (1)<br />

on the survey date.<br />

Title<br />

Date<br />

Agency<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

14<br />

YES I NO YES I NO<br />

This Is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

Date<br />

School District<br />

This information Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Federal Property:<br />

SHAVONE DAVIS PICKETT<br />

LATANYA JACKSON<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003015 Address: 2530 9TH AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

2530 9TH AVE #101<br />

2530 9TH AVE #202<br />

Number Students At This Property 2<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

Signature Date Signature<br />

Title<br />

Agency<br />

YES I NO YES I NO<br />

x<br />

X<br />

Rasaun Freeman<br />

Marsharel Simon<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Title<br />

Date<br />

School District<br />

11/5/1997<br />

12/14/1996<br />

This <strong>In</strong>formation is the basis for payment to this school district of federai funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.<br />

5<br />

5


Signature<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003016 Address: 1248 E 34TH ST<br />

(i) (2) (3) (4) (5) (6) (7) (S)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (i) <strong>In</strong> Column (i) Parent/Guardian <strong>In</strong> Date of Grade<br />

if applicable) lived on worked on Column (i) Birth<br />

or above properly above properly<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES T NO<br />

ALICE BYERS-BIGGINS 1248 E 34th St#101 x A10nteBiggins 5/20/1996 6<br />

Lisa Pace 2451 RENWICK ST #104 X Freddie Dunbar 1/7/1992 9<br />

Edana Evans 554 37TH ST #202 X Joshua Evans 11/12/1998 4<br />

Kimberly Keesee/Belty Scotl/An 2451 Renwick Sl #103 X Kris Fletcher 7/29/2001 1<br />

APRIL FORD 1246 E 34TH ST #302 X Timothy Ford 6/6/1997 5<br />

Joh/Ashanti Fullard 2451 Renwick SI#103 X Jalen Fullard 3/1011999 3<br />

FAYE WALKER 1248 E 34TH ST #301 X Tommy Gates 2/14/1993 9<br />

FAYE L. WALKER 1248 E 34TH ST #301 X TomyGates 2/14/1993 9<br />

Teresa Jackson 554 37TH ST #303 X Roderick Godfrey 1/15/1997 4<br />

EDANA EVANS 554 37TH ST #202 X Antonio Harris 8/611994 8<br />

Harvey, Olivia 554 37th St #302 X Andre Harvey 5/4/1997 5<br />

Denise Harvey 554 37th St #302 X Angelina Harvey-Mendez 11/8/2001 1<br />

WILLIE & DELORES HILL 2529 9TH AVE #103 X AlaniHiII 5/15/1996 6<br />

DELORES HILL 2529 9TH AVE #103 X Jakari Hill 12/15/1998 3<br />

This is to certify that the <strong>In</strong>fonmation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) is correct for the person listed under Column (1)<br />

This is to certify that the infonmatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

on the survey date.<br />

Title<br />

Date<br />

Agency<br />

Signature<br />

Title<br />

Date<br />

School District<br />

This information Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation. •


-------- ------------------------------------------------,


FederalProperty:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003016 Address: 1248 E 34TH ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Teresa Jackson 554 37th St #303 X Tejanee Jackson 3/4/1990 11<br />

CHRISTINE SMITH 2529 9TH AVE #104 X lamia Jenkins 6/15/1998 4<br />

CHRISTINE SMITH 2529 9TH AVE #104 X<br />

Tanals Johnson 2451 Renwick St #102 X<br />

Tamya Jenkins 6/15/1998 4<br />

ChnstopherJohnson 6/30/1996 6<br />

Tanals Johnson 2451 Renwick St #102 X Delesha Johnson 12/1/1999 2<br />

CHRISTINE SMITH 2529 9TH AVE #104 X<br />

Tatiana Johnson 5/9/1994 6<br />

RAYMEN JUSTICE 1323 MACARTHUR BLVD #5 X Rayman Justice 2/11/1993 8<br />

RAYVEN JUSTICE 1323 MACARTHUR BLVD #5 X Rayven Justice 8/13/1991 10<br />

CUONGLAM 1246 E 34TH ST #202 X Judy Lam 3/2/1992 10<br />

CUONG/KIU LAM 1246 E 34TH ST #201 X Mimi Lam 4/22/1995 7<br />

DANETTE MONTGOMERY 1323 MACARTHUR BLVD #2 X Jermaine Mason 9/9/1990 11<br />

Alice Esters 2451 Renwick SI #104 X<br />

Jonathan Pierce 2/18/1997 5<br />

Alice Esters 2451 Renwick St #104 X Tre'Van Pierce 1/9/1996 5<br />

ALMA BLACKWELL 554 37th St #102 X Kimani Reynolds 8/14/1992 10<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature<br />

TItle<br />

Agency<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the sUlVey date.<br />

Title<br />

Date<br />

School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


FederalProperty:<br />

SHIRLEY WILLIAMS<br />

SHIRLEY WILLIAMS<br />

ZHIYUANWU<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003016 Address: 1248 E 34TH ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

1248 E 34TH ST #201<br />

1248 E 34TH ST #201<br />

1248 E 34TH ST #202<br />

Number Students At This Property 31<br />

This Is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Date<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES<br />

x<br />

I NO YES I NO<br />

X<br />

X<br />

Dannae Washington<br />

Keshia Washington<br />

ANNIEWU<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title Agency Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title Viii of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.<br />

Date<br />

1/16/1990<br />

1/26/1991<br />

1/912002<br />

12<br />

10<br />

o


Federal Property:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003017 Address:<br />

9008 CHERRY ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

ANDREWS ONTARIO 9008 CHERRY ST #3<br />

Ontario Andrews 9008 Cherry St #3<br />

Nakeya Thomas 9008 Cherry St #4<br />

JENKINS, LAVINIA 9008 Cherry St #1<br />

Number Students At This Property<br />

This Is to certify that the infonmation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

TItre<br />

Date<br />

Agency<br />

4<br />

YES I NO YES I NO<br />

X Jamika Baker 812011996 5<br />

X Yasmine Baker 211712001 1<br />

X<br />

Ronnie Campbell 4118/2000 2<br />

X Ken Harbin Jr 2111/1995 7<br />

This Is to certify that the infonmation shown under columns (4) and (6)<br />

of the foregoing sheat(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

Date<br />

School District<br />

This <strong>In</strong>fonmatlon is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIll of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003018 Address: 3532 PIERSON ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Latanya Douglas 3532 Pierson St #4 X Deandre Douglas-Richards 12130/1998 3<br />

Terry, Lakeiva 3532 Pierson St #5 X Anlwan Jackson 5/15/2001 0<br />

Suzanna Pineda 3532 Pierson St #5 X Khristopher Martinez 6/8/1998 4<br />

lakeiva Terry 3532 Pierson St #5 X Wilneisha Patterson 8/24/1999 2<br />

Terry, LakeivaiRoyal,Keon 3532 Pierson St #5 X Keondra Royal 10/26/2002 0<br />

LATANYA DOUGLAS 3532 PiERSON ST #4 X Tremaine Wheaton 7/30/1991 11<br />

LATANYA DOUGLAS 3532 PIERSON ST #4 X Trevonn Williams 4/9/1994 8<br />

Number Students At This Property 7<br />

This Is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

This is to. certify that the information shown under columns (4) and (5)<br />

olthe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency TItle School District<br />

This <strong>In</strong>formation is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for thIs school district to receive funds based on this <strong>In</strong>formation.


Signature<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003019 Address: 2558 35TH AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

VALERIE PARKER 2558 35TH AVE #10 X Markell Brooks 5/24/1998 4<br />

SharenaiDawa Curley 2558 35th Ave #7 X Dante Curley 9/15/1999 2<br />

JININAKEYS 2558 35TH AVE #5 X Shanlna Hill 6/16/1990 11<br />

Samphors Wok 2558 35th Ave #5 X Sovann Kay Jr 11/11/2001 1<br />

JININAKEYS 2558 35TH AVE #5 X Akeena Keys 10/14/1993 9<br />

LEWAN YANG 2558 35th Ave #9 X Dorothy Le 11/15/1996 5<br />

Sarita Panngasiri 2558 35th Ave #3 X Thaila Mannorind 1/19/2000 2<br />

Ardrea Perry 2558 35th Ave #4 X De Vante Monroe 2/24/1994 7<br />

VON MORRIS 2558 35TH AVE #4 X Akirra Morris 10/12/1996 5<br />

Ardrea Perry 2558 35th Ave #4 X Alexuis Morris 9/17/1995 6<br />

Von Douglas Manis/Andrea Perr 2558 35th Ave #4 X Savonte Morris 5/12/2002 0<br />

VON MORRIS 2558 35TH AVE #4 X Von Morris Jr 3/5/1997 4<br />

SAMPHORS NOK 2558 35TH AVE #6 X Arna <strong>No</strong>k 612711990 11<br />

KHAMKHEUANG PANNGASIRI 2558 35th ave #3 X Sharleen Panngasiri 7/25/1990 11<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5) This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1) of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

on the survey date.<br />

Date Signature<br />

Title Agency Title<br />

School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.<br />

Date


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003019 Address: 2558 35TH AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) in Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Valeria Parker 2558 35th Ave #10 X Adam Parker 6/30/1993 9<br />

VALERIE PARKER 2558 35TH AVE #10 X Katelyn Parker 2/7/1991 10<br />

Sonltha Sil/Mike En 2558 35th AVe #11 X Lana Res 1211612001 0<br />

Sokun Sit 2558 35th ave #11 X Lily Res 8/27/2000 2<br />

MUEYCHAO 2558 35TH AVE #8 X Franklin Saephanh 11/7/1992 10<br />

Valerie Parker 2558 35th Ave #10 X Makaylia Smith 5/23/2001 1<br />

Sharena N. Thomas 2558 35th Ave #7 X Augenique Thomas 12117/1994 7<br />

Number Students At This Property 21<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

This is to certify that the information shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature<br />

Date<br />

Title Agency Title School District<br />

this <strong>In</strong>formation is the basis for payment to this school district oUederal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


------------------------------------ -


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

Federal Property: CAO03020 Address: 2272 E 19TH ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Maria Lott 2272 E 19th St #1 X Michaela Allums 9/21/1999 3<br />

ALICIA GRAYSON 1750 E 21ST ST #4 X Shaneeka Harris 5nJ1994 7<br />

RASHIMA BELLAMY 1750 E 21ST ST #1 X Jzanik Hicks 8/15/1992 10<br />

ALICE GRAYSON/ALICIA GRA 1750 E 21ST ST #4 X Marcellous Lewis 12119/1990 9<br />

Dynese Horace 1750E21stSt#5 X A10nLynn-Hurth 10/15/1996 5<br />

DEVONEE BELLAMY 1750 E 21ST ST #1 X Fronchonte Stewart 3/2211994 8<br />

LUANTRUONG 2272 E 19th St #2 X Tho Tran 10/13/1991 10<br />

THACH TRANITRUONG LUAN 2272 E 19th St #2 X Truong Tran 2124/1990 12<br />

MARIALOTT 2272 E 19TH ST #1 X Kamillah Webb 8/31/1994 7<br />

Number Students At This Property 9<br />

This is to certify that the <strong>In</strong>fonmation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

This is to certify that thelnfonmation shown under columns (4) and (5)<br />

of the loregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title School District<br />

This <strong>In</strong>lonmation Is the basis for payment to this school district 01lederal funds under the Impact Aid Program (TItle Viii of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Federal Property:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003021 Address: 2261 84TH AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Alice & Robert Woods 2261 84th Ave #1 X Ashley Bebbinglon-Woods 8/1212000 2<br />

Markeya Holcomb 2255 84TH AVE #4 X Shawnee Ivory 12114/1995 5<br />

MARKEYA HALCOMB 2255 84TH AVE #4 X Marcel Jackson 5/15/1994 7<br />

TAMECIA JESSIE 6121 HARMON AVE #2 X Jarell Jessie 4/211993 8<br />

TAMECIA JESSIE 6121 HARMON AVE #2 X Mareisha Jessie 6/6/1996 6<br />

PATRICIA TOWNES 6121 HARMON AVE #1 X Tariq Lloyd 4/20/1991 10<br />

PATRICIA TOWNES 6121 HARMON AVE #1 X Temetrius Lloyd 5/29/1995 7<br />

CARMENGAAR 6121 Harmon Ave #3 X Jamaica Russell 5/2211998 4<br />

CARMENGAAR 6121 Harmon Ave #3 X Javan Russell 5/2211998 4<br />

Cart Rivero ThreetslKawana Sim 6121 Harmon Ave #1 X Cart Threets 4/21/1994 8<br />

Cart Threets/Kawana Simmons 6121 Harmon Ave #1 X Carrell Threets 5/23/1996 6<br />

LAMONT/SHAWNRIKA WHITE 2261 84th Ave #3 X Lamonica Gear White 8/13/1997 5<br />

LAMONT WHITE 2261 84th Ave #3 X Lavell White 1017/1999 3<br />

Number Students At This Property 13<br />

This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Date<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title Agency Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title Viii of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.<br />

Date


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003022 Address: 1900 E 24TH ST#<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

ANGELA DOSSMAN 1900 E 24TH ST #C X Samuel Bemstine III 5/22/1991 10<br />

ANGELA DOSSMAN 1900 E 24TH ST #C X Stantasia Dossman Bishop 5/811995 7<br />

ANGELA DOSSMAN 1900 E 24TH ST #C X Levi Dossman-Mitchell 8/9/1993 8<br />

CAVENIA BRYANT&RONDELL 1900 E 24TH ST #B X Tajae Hendon 8/14/1996 6<br />

THOU LIM 1900 E 24TH ST #D X Robema Lim 10/8/1993 7<br />

Lim, Thou 1900 E 24th St #D X Thomas Pal 4/25/2001<br />

Lakeisha Owens 1900 Commerce Way #E X Rodkei Royal 8/5/1998 3<br />

NAISAEPHAN 1900 E 24TH ST #A X KaoSaephan 3/11/1992 10<br />

Debora Mcfadden 1900 COMMERCE WAY #A X Andre Smith 3/19/2002 0<br />

Debbie McFadden 1900 Commerce Way #A X Andrew Smith 9/26/1999 3<br />

DEBORA MCFADDEN 1900 Commerce Way #A X Tamara Smith 5/24/1996 5<br />

ALICE OLIVER 1900 Commerce Way #B X Tonisha Smith 12/17/1998 3<br />

ALICE OLIVER 1900 COMMERCE WAY #B X Destany Smith-Oliver 3/10/1998 4<br />

Dorothy Bryant 1900 E 24th st #B X Javan Williams 8/24/1991 10<br />

This Is to certify that the <strong>In</strong>fonmatlon shown under columns (4) and (5) This Is to certify that the <strong>In</strong>fonmatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1) of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature<br />

Title<br />

Date Signature Date<br />

Agency TItle School District<br />

This <strong>In</strong>fonmatlon Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003022 Address: 1900 E 24TH 5T #<br />

(l) (2) (3) (4) (5) (6) (7) (S)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (l) <strong>In</strong> Column (l) Parent/Guardian <strong>In</strong> Date of Grade<br />

If appilcable) lived on worked on Column (l) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

Number Students At This Property 14<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

YES I NO YES I NO<br />

This Is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title<br />

School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle Viii of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


-----------------------------------------------------------------_. --------


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003023 Address: 675 30TH #<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Coiumn (1) <strong>In</strong> Coiumn (1) Parent/Guardian in Date of Grade<br />

if applicabie)<br />

or<br />

lived on<br />

above property<br />

worked on<br />

above property<br />

Coiumn (1) Birth<br />

r<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

CAROL CHRISTOPHER 675 30TH ST #5 X Jazz Christopher 1/31/1995 7<br />

CAROL CHRISTOPHER 675 30TH ST #5 X Lashayla Christopher 5/24/1993 8<br />

TASHA LANDRY 675 30th St #3 X Jayvon Landry 8/12/1995 7<br />

Monlque Green/Sirclinton Nelso 675 30th St #1 X Dejah Nelson 712112001 1<br />

Anthony Pierce 675 30th St #2 X Lavonte Pierce 4/14/1992 9<br />

Number Students At This Property 5<br />

This is to certify that the information shown under columns (4) and (5)<br />

olthe foregoing sheet(s) is correctfor the person listed under Column (1)<br />

on the survey date.<br />

This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title School District<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (Title Viii of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003024 Address: 2229 E 24TH ST #<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

FREDERICK JORDAN 2229 E 24th SI #2 X Brianna Jordan 12/27/1991 10<br />

ENNIS/SONDRA WINN 2229 E 24TH ST #1 X Genoa Winn 5/31/1995 7<br />

Sondra/Ennis Winn 2229 E 24th SI #1 X PhillipWinn 5/4/1991 10<br />

Number Students At This Property 3<br />

This is to certify that the information shown under columns (4) and (5)<br />

olthe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Agency Title School District<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


- ----------------------------------------


FederalProperty:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003025 Address: 3314 E 17TH ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

JANICE BOBBS/JARED TUT TL 3316 E 17TH ST X Kevin Henry Jr 10/24/1995 7<br />

Ambree Hewitt 3318 E 17th ST X Kenae Shepard 4/11/2002 0<br />

Jared Tuttle/Janice Bobbs 3316 E 17TH ST X Londyn Tuttle 7/26/2001 1<br />

Number Students At This Property 3<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school distrIct to receive funds based on this information.


Federal Property:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003026 Address: 2416 88TH AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES T NO YES I NO<br />

Samban Hem 2416 88TH AVE #3 X Xavier Joseph 8/6/1997 5<br />

IKIMIA L. KING 76841ST ST#1 X lakiriyya Karimusha 6/27/1995 7<br />

KIM MURPHY 768 41ST ST #2 X Kelton Runnels 2110/1997 5<br />

KIM MURPHY 76841STST#2 X Khalanl Runnels 5/19/1999 3<br />

MYRNA MCDANIEL 76841STST#6 X Emari Walker 10/16/1998 3<br />

MYRNA MC DANIEL 76841ST ST#6 X Edmond Walker IV 91711996 5<br />

TOUCHYONG 768 41ST ST #3 X Johnny Yonq 11/3/1996 5<br />

TOUCHYONG 76841STST#3 X KellyYon9 1219/1990 10<br />

Number Students At This Property 8<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Coiumn (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Eiementary and Secondary Education Act).<br />

this form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003027 Address: 9510 SUNNYSIDE ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

ParenUGuardian's ParenUGuardian's Branch of Service ParenUGuardian ParenUGuardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) ParenUGuardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Owens, Nicole 9510 Sunnyside St #3 X DaVonte Blackston 12/21/1996 5<br />

NICOLE OWENS 9510 Sunnyside St #3 X Jazmyne Blackston 10/29/1994 8<br />

LAMONT BUNDY 9500 SUNNYSIDE ST #5 X Lamont Bundy 4/30/1994 7<br />

BRENDA ALLEN 2032 E 26TH ST #1 X Jasmine Carter 3/811992 10<br />

KATRINA PERRY 9500 SUNNYSIDE ST #8 X Jerrell Chadwick 3/3/1991 11<br />

MOM OUCH 2023 24TH AVE #1 X Henry Chan 2/28/1992 10<br />

Bobbie Sanders 1815 28th Ave #2 X Demarcus Coleman 1/14/1994 8<br />

NIKIEVANS 9510 SUNNYSIDE ST #7 X Derrick Comell Jr 11/5/1994 8<br />

Tamisha Wshington/<strong>No</strong>rice Dilw 1815 28th Ave #4 X Vashown Dilworth 6/17/2002 0<br />

Nakia Dupaly 1815 28th Ave #1 X Jeremiah Ellis 2/4/1998 3<br />

KATRINA PERRY 9500 SUNNYSIDE ST #8 X Kenard Figg 1/15/1998 3<br />

Sherley Johnson 2021 24th Ave #2 X Antonae Guillory 8/14/1998 3<br />

SHIRLEY JOHNSON 2021 24th Ave #2 X Alexis Johnson 4/19/1996 6<br />

LA'TANYA JACKSON 2032 E 26th St #8 X Michael Johnson 4/5/1993 9<br />

This is to certify that the <strong>In</strong>fonmatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

This is to certify that the <strong>In</strong>fonmation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date<br />

Signature Date<br />

Title<br />

Agency<br />

Title<br />

School District<br />

This infonmation is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003027 Address: 9510 SUNNYSIDE ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

ANGELA ALLEN/Rodney Rucke 2032 E 26TH ST #9 X Mohammad Jones 7n/1994 8<br />

ANGELA ALLEN 2032 E 26th St #9 X Olivia Jones 5/15/1992 9<br />

Toccara Palmer 7908 Ney Ave #3 X Deantae Kennedy Palmer 4/15/1997 5<br />

Elanda West 2032 E 26th ST #8 X Haley Lane 11/3/2001 0<br />

ERNESTO MARTINEZ 9500 SUNNYSIDE ST #3 X ELIAS MARTINEZ 8/27/2002 0<br />

Brenda Martin 7908 Ney Ave #1 X Erick McAdoo 9/30/2000 1<br />

SHAMEKA WILLIAMS 9510 SUNNYSIDE ST #8 X <strong>In</strong>dia Mccall 1/17/1998 4<br />

TONYA HARRIS 2032 E 26th St #1 X Dominique <strong>No</strong>el 8/25/1991 11<br />

AVIS OSIVWEMU 9500 Sunnyside St #7 X Luke Osivwemu 5/20/1994 8<br />

Jalita Johnson 1815 28th Ave #5 X Erica Richardson 2/18/1991 10<br />

WANDA GREENWOOD 9510 SUNNYSIDE ST #6 X Tashauanna Richmond 5/30/1995 6<br />

SHIEDA RIDLEY 7908 Ney Ave #5 X Champayne Ridley 3/3/1995 7<br />

Melvin Johnson/Shieda 7908 Ney Ave #5 X Zaria Ridley 8/14/1997 5<br />

SHALONDA THOMPSON 2021 24th Ave #3 X Elvan Shannon 1/31/1996 6<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5) This Is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1) of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature<br />

Title Agency<br />

Date Signature Date<br />

Tille School District<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information. '


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

Federal Property: CA003027 Address: 9510 SUNNYSIDE ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Mliltary as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

KATRINA PERRY 9500 SUNNYSIDE ST #8 X Rickeya Smith 4/26/1995 7<br />

Tamla Lipscomb 7908 NEY AVE #1 X Michaela Stamps 7/29/1998 4<br />

BRENDA MARTIN 7908 NEY AVE #1 X Dale Starks Jr 3/18/1993 8<br />

NIKI EVANS 9510 SUNNYSIDE ST #7 X TATIANNA STEWART 3/1212002 0<br />

SHIEDA RIDLEY 7908 Ney Ave #5 X Andrew Thomas 9/6/1992 9<br />

Samun KeamlRonth Kearn 2023 24th Ave #1 X Sokchanthra Uch 2114/2000 2<br />

Ronth Kearn 2023 24th Ave #1 X Cita Va 10/18/2002 0<br />

LEVETTE M. BUFFIN 9500 SUNNYSIDE ST #5 X Arrianna Varello 4/27/1999 3<br />

LATASHA THOMAS 2032 E 26th St #5 X Dejan Vasquez 5/211994 8<br />

LATASHA THOMAS 2032 E 26TH ST #5 X Tashawna Vasquez 1211311990 11<br />

TARNISHA WASHINGTON 1815 28th Ave #4 X Tayjah Washington 1/1211995 7<br />

HANNIBAL WILLIS 1815 28th Ave #10 X Brianna Willis 5/13/1993 8<br />

ERICKA WILLIAMS/Hannibal Wi 1815 28TH AVE #10 X Hannibal Willis Jr 4/28/1996 6<br />

Owens Nicole 9510 Sunnyside St #3 X Markell Wooley 1/1/2000 2<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5) This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1) ofthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature Date Signature<br />

Date<br />

Title Agency Title School District<br />

This information Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Annette Boyd<br />

ANNETTE BOYD<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003027 Address: 9510 SUNNYSIDE ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

7908 Ney Ave #4<br />

7908 NEY AVE #4<br />

Number Students At This Property 44<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

YES I NO YES I NO<br />

x<br />

X<br />

Kiaira Wright<br />

Tiaira Wright<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

TItle Agency Tille School District<br />

10/6/1998<br />

3123/1994<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title Viii of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.<br />

4<br />

8


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003028 Address: 7209 HOllY ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address {including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Theresa Batts 7209 Holly St #1 X Anthony Batts 10/18/2001 1<br />

THERESA BATTS 7209 HOLLY ST #1 X Ladarius Batts 6/21/1991 11<br />

THERESA BATTS 7209 HOLLY ST #1 X Destiny Gray 6/18/1999 3<br />

THERESA BATTS 7209 HOLLY ST #1 X O'Onshana Holmes 2/16/1994 8<br />

ERSULA CAPERS 7209 HOLLY ST #2 X Brittney Jones 4/30/1990 11<br />

Batts TheresaJErsula Capers 7209 Holly St #2 X Eric Radford 4/16/1992 9<br />

Number Students At This Property 6<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature<br />

Date<br />

Title Agency Title<br />

School District<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003029 Address: 2030 E 25TH ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

GLORIA GONZALEZ 2030 E 25TH ST #5 x Tiffany Ramirez 10/14/1992 10<br />

Number Students At This Property 1<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Agency Title School District<br />

This information Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Signature<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003030 Address: 1739 89TH AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

EVORA JACKSONIMARLON F 1739 89th Ave #5 X Shamara Fountain 10/25/1990 11<br />

YOLONDA SCOGGINS 1739 89th Ave #4 X Dante Gohleston 12118/1990 11<br />

Kathleen Hewitt 4005 LYON AVE #5 X Devonte Hewitt 7/1/1991 9<br />

IIESHA K. MOOREIStephanie W 1739 89TH AVE #2 X Elisha Johnson 9/1411994 7<br />

VENUS POLK-SPENCER 4005 Lyon Ave #5 X Vanessa Spencer 1218/1990 11<br />

Martell WashingtonlCorey Picke 4005 Lyon Ave #5 X Marshay Washington-Estes 1/11/2002 0<br />

Number Students At This Property 6<br />

This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Title Agency Title<br />

School District<br />

This information Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.<br />

Date


Federal Property:<br />

(1)<br />

Parent/Guardian's<br />

Name<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003031 Address:<br />

(2) (3)<br />

(4)<br />

Parent/Guardian's<br />

Address<br />

Parent/Guardian<br />

<strong>In</strong> Column (1)<br />

lived on<br />

above property<br />

as of<br />

survey date<br />

YES I NO<br />

Yvette Gross 251111lh Ave #0 x<br />

CHAMDEAU PLOYNGAM (DAD 2511 11TH AVE #8<br />

CHAMDEAU PLOYGRAM (DAD 251111TH AVE #8<br />

Branch of Service<br />

(<strong>In</strong>cluding rank,<br />

If applicable)<br />

or<br />

Foreign Military<br />

Government<br />

Number Students At This Property 3<br />

This Is to certify that the information shown under columns (4)and (5)<br />

olthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

X<br />

X<br />

251111THAVE<br />

(5) (6) (7)<br />

(8)<br />

Parent/Guardian<br />

<strong>In</strong> Column (1)<br />

worked on<br />

above property<br />

as of<br />

survey date<br />

YES I NO<br />

Name of Pupil Living With<br />

Parent/Guardian <strong>In</strong><br />

Column (1)<br />

Orlando Jr Johnson<br />

DaraPloyngam<br />

Pichsavong Run<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4)and (5)<br />

olthe foregoing sheet(s)Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency<br />

Title School District<br />

Pupil's<br />

Date of<br />

Birth<br />

4/8/2000<br />

2/11/1995<br />

4/13/1996<br />

This <strong>In</strong>formation is the basis for payment to this school district of federal funds under the Impact AId Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.<br />

Pupil's<br />

Grade<br />

2<br />

6<br />

5


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003032 Address: 4908 CONGRESS AVE<br />

(1) (2) (3) (4) (5) (5) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil living With, Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Govemment survey date survey date<br />

YES I NO YES I NO<br />

Aaesha Holloway/Jermaine Brya 4908 Congress Ave #2 X Jermanl Bryant 12110/2000<br />

MILEHANNAH PERRY 4908 Congress Ave #3 X MARIO GANT JR 5/29/2002 0<br />

Latanya Robinson 4908 Congress Ave #1 X Tkeyah Poco 3/2211991 10<br />

WILLIE SCOTT 1599 54TH AVE #3 X Willie Scott 4110/1995 7<br />

TINISHA GRAY 1599 54TH AVE #3 X Taylor Simmons 12117/1994 7<br />

Latanya Robinson 4908 Congress Ave #1 X Tamia Swann 1/25/1995 6<br />

Number StUdents At This Property 6<br />

This is to certify that the infonmatlon shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the sUlVey date.<br />

This is to certify that the infonmatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the sUlVey date.<br />

Signature Date Signature<br />

Date<br />

Titie Agency Title<br />

School District<br />

This <strong>In</strong>fonmation is the basis for paymentto this school district of federal funds under the Impact Aid Program (TItle VIII ofthe Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003033 Address: 5009 CONGRESS AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

PAMELA BROWN 5009 Congress Ave #1 x Avante' Arrington 2/11/1992 9<br />

Number Students At This Property 1<br />

This Is to certify that the information shown under columns (4) and (5)<br />

ofihe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

This is to certify that the information shown under columns (4) and (5)<br />

ofihe foregoing sheet(s) Is correcltor the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Tille Agency Till. School District<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Georginna Hanson<br />

Jackie Turner<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003034 Address: 7204 HOllY ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil liVing With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

GEORGIANA HANSON & TELL 7204 HOLLY ST #2<br />

7204 Holly SI #2<br />

7204 Holly St #3<br />

Number Students At This Property 3<br />

This is to certify that the infonnation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

YES<br />

x<br />

I NO YES I NO<br />

X<br />

X<br />

Chauncey Davis<br />

Te'Giana Davis<br />

Jessica Turner<br />

This Is to certify that thelnfonnatlon shown under columns (4) and (5)<br />

olthe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature<br />

Date<br />

Title Agency Title School District<br />

This <strong>In</strong>fonnatlon Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.<br />

9/24/1995<br />

3/28/1999<br />

817/1991<br />

7<br />

3<br />

10


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003035 Address: 6916 ARTHUR ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Terrel & Kaya Sidney 6916 Arthur St #A X Terreli Beker 5/14/1997 4<br />

Myisha Myrick 2626 E21stSt#C X Auntrice Brooks 9/3/2001<br />

MYISHA MYRICK 2626 E 21ST ST #C X Jayla Brooks 1/17/1996 6<br />

CHATISSE MATHEWS 1521 92ND AVE #B X Earnest Henderson 11/25/1996 6<br />

CHATRISSE MATHEWS 1521 92ND AVE #B X Tierra Henderson 3/19/1994 6<br />

Ynagnaca Dixon 2626 E 21st St #A X Hemaciona Henry 4/19/1992 10<br />

Juliette Hutchinson 2626E21stSt#D X Nakiyah Hutchinson 2/21/1990 12<br />

WYNONA PRICE 9711 SUNNYSIDE ST #B X Christilyn Mcneal 8/18/1991 10<br />

ANNICE EVANS 9711 SUNNYSIDE ST #E X Angel Ramos 6/3/1995 7<br />

ANNICE EVANS 9711 SUNNYSIDE ST #E X Dante Ramos 10/16/1996 6<br />

NATASHA JENKINS 6916 ARTHUR ST #B X Tah'Ree Razo 6/8/1997 5<br />

Labrina McClainlEmsto Rosales 1521 92nd Ave #E X Luzelena Rosales 1/19/1998 4<br />

ANNICE EVANS 9711 SUNNYSIDE ST #E X Antionetle Saddler 8/24/1993 9<br />

Number Students At This Property 13<br />

This is to certify that the infonnatlon shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correctfor the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

This is to certify that the infonnatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Agency Title School District<br />

This infonnation is the basis for payment to this school district of federal funds under the Impact Aid Program (TIlle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for thIs school district to receive funds based on this information.


,<br />

..._._--_.


(1) (2) (3) (4) (5) (6) (7) (8)<br />

ParentlGuardian's ParentlGuardian's Branch of Service ParentlGuardian ParentlGuardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) ParentlGuardian <strong>In</strong> Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

ALYSIA LUCAS<br />

SAECHAO MANH<br />

SHIDAH SHABAZZ<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003036 Address: 2146 E 24TH ST #<br />

2146 E 24TH ST #B<br />

2146 E 24th ST #A<br />

2146 E 24th SI #C<br />

Number Students At This Property 3<br />

This Is to certify that the <strong>In</strong>fonnatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s)is correct for the person listed under Column (1)<br />

on the survey date.<br />

YES I NO YES I NO<br />

x<br />

X<br />

X<br />

LakiraMcClain<br />

Brian Saechao<br />

MalikahShabazzBowie<br />

This Is to certify that the <strong>In</strong>fonnation shown under columns (4) and (5)<br />

olthe foregoing sheet(s)Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title<br />

Agency Title School District<br />

9/3/2002<br />

12/19/1993<br />

This <strong>In</strong>fonnation Is the basis for paymentto this school district of federalfunds under the Impact Aid Program(TItleViii of the Elementaryand SecondaryEducation Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.<br />

2/5/1991<br />

o<br />

8<br />

11


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003037 Address: 2216 E 21ST ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

SONJA J. CHATMAN 2212 E 21st St #A X Laray Davis 11/2211992 9<br />

RELONDASHY 2216E21StSt#B X Myelsha Shennan 3/6/1991 10<br />

RELONDA SHERMAN 2216 E 21stSt#B X Delano Shennan III 4/5/1993 9<br />

Carolyn Payne 2216 E 21st ST #A X Maurichia Turner 2111/1990 10<br />

Number Students At This Property 4<br />

This Is to certifY that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

This is to certifY that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title<br />

School District<br />

This information Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title Viii of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


----------------------------------------------


Signature<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003038 Address: 2323 E 22ND ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if appilcable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

LATISHA FREDERICK 2323 E 22ND ST #2 X Jahsaun Brown 8/20/1997 5<br />

LATOYA LEWIS VARNEDOE 2170 E 28TH ST #10 X Saryna Fields-Vamedoe 4/14/1999 3<br />

SHARON WHITE 2323 E 22ND ST #4 X Desmond Gipson 1/28/1997 4<br />

Charles & Sandra Green 2170 E 28TH SI#10 X Tiesha Green 9/29/1997 5<br />

LASHANA JUSTIN 2630 E 25th St #3 X Kerriana Justin 9/9/1993 8<br />

La Shana Justin 2630 E 25th SI #3 X Kyra Justin 5/1/1999 3<br />

KRISTINA LIPSCOMB 2630 E 25th St #1 X Mikel Meadows 6/29/1998 4<br />

Ernestine Beny 2323 E 22nd SI #3 X Sitkiya Simmons 8/5/2002 0<br />

MONICA SUN 2323 E 22ND ST #5 X Diana Sun 1/26/1996 6<br />

Number Students At This Property 9<br />

This Is to certify that the <strong>In</strong>fonnatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature<br />

This is to certify that the <strong>In</strong>fonnatlon shown under columns (4) and (5)<br />

oflhe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Title Agency Title School District<br />

This infonnatlon Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.<br />

Date


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003039 Address: 2315 98TH AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil liVing With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

GERALDINE WILLIAMS 2317 98TH AVE #3 X Ebony Donnley 5/2211990 12<br />

Tabasamu Barksdale 2317 98th Ave #2 X Dayshia Gaines 9/16/1996 5<br />

Tabasamu BarksdalelRay Gain. 2317 98th Ave #2 X Destiny Gaines 7/11/2000 1<br />

Carter, Michelle Renee 2317 98th Ave #1 X Makayla Surrell 5/28/1998 3<br />

Michelle Renee carter 2317 98th Ave #1 X Makeal Surrell 8/1/1999 3<br />

Carter, Michelle Renee 2317 98th Ave #1 X Makiya Surrell 11115/2000 2<br />

Number Students At This Property 6<br />

This Is to certify that the information shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correclfor the person listed under Column (1)<br />

on the survey date.<br />

This Is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Federal Property:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003040 Address: 2402 E 27TH ST<br />

Signature<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

DARLENE DAVISfTALCE EVAN 2402 E 27TH ST #7 X Talce Evans 1/13/1993 9<br />

Myeesha Harris 2402 E 27th St #5 X Tyrese Franklin 8/27/2000 2<br />

Desiree Bradford 2402 E 27th St #4 X Isaiah Jackson 9/25/2002 0<br />

Desiree R. Bradford 2402 E 27TH ST #4 X Lavell Jackson 11/3/1995 6<br />

Desiree Bradford 2402 E 27th St #4 X 8t James Jackson 7/16/1997 5<br />

KRiSTY HEI LUM WANG 2402 E 27TH ST #3 X Ashley Li 1/15/1999 3<br />

KRISTY H. WANG 2402 E 27TH ST #3 X Cody Li 3/21/1996 6<br />

KRISTY HEI LUM WANG 2402 E 27TH ST #3 X Emily LI 1/15/1999 3<br />

KRISTY H. WANG 2402 E 27TH ST #3 X Erica Li 2/25/1997 5<br />

TERESA DOUGLAS 2402 E 27th St #8 X Tyree McCoy 4/11/2001 1<br />

CHANNAMEY 2402 E 27TH ST #2 X Amanda Mey 5/14/1991 11<br />

SHEREE R. HOLLINS 2402 E 27TH ST #1 X Raeshonna Smith 1/2011995 5<br />

SHEREE HOLLINS 2402 E 27TH ST #1 X Roland Smith Jr 2/1/1995 7<br />

MYEESHA HARRIS 2402 E 27TH ST #5 X Tahjanay Ward 12/2/1995 7<br />

This Is to certify that the information shown under columns (4) and (5)<br />

olthe foregoing sheet{s) Is correct for the person listed under Column (1)<br />

This Is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet{s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

on the survey date.<br />

Title<br />

Date<br />

Agency<br />

Signature<br />

Title<br />

Date<br />

School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003040 Address: 2402 E 27TH ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

Number Students At This Property 14<br />

This is to certify that the information shown under columns (4) and (5)<br />

olthe foregoing sheet(s) is correctfor the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

YES I NO YES I NO<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Agency Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (Tille VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


...-------------------------------


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003041 Address: 8330 BANCROFT AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Vivian Enoch 2225 84th Ave #2 X Dominique Cordell 3/26/1991 9<br />

Sadaga Salaam 2225 84th Ave #4 X Jailynn Gatson 8/8/2000 2<br />

Shiwishi Boyd 2225 84th Ave #1 X Jasmine Lowery 4/7/1998 4<br />

Shiwish Boyd 2225 84TH Ave #1 X Robert Lowery Jr 7/1/1996 5<br />

LISA L. SMITH 8330 Bancroft ave #1 X Alexzandra Smith 3/24/1994 8<br />

BRIDGET WAFER 2225 84th ave #3 X Brittney Wafer 4/18/1994 8<br />

LONNIE WHITE/Bridget Wafer 2225 84th Ave #3 X Lonnie Wafer 12/18/1991 9<br />

Number Students At This Property 7<br />

This is to certify that the <strong>In</strong>fonnatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

This Is to certify that the <strong>In</strong>fonnatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title School District<br />

This <strong>In</strong>formation is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


.---------------------------------------------


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003042 Address: 2219 E 22ND ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

HUNG LAC / CHEN T. YING 2219 E 22ND ST #4 x Lisa Lac 9/211993 9<br />

Number Students At This Property 1<br />

This is to certify that the infonnation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

This Is to certify that the infonnation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency<br />

Title School District<br />

This infonnation is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003043 Address: 2246 E 19TH ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service ParentiGuardlan ParentiGuardlan Name of Pupil Living With. Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) ParentiGuardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

LATRICEPORTER 2240 E 19TH ST #1<br />

Lucretia Henderson<br />

2240 E 19thSt#2<br />

Number Students At This Property 2<br />

This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

YES I NO YES I NO<br />

x<br />

X<br />

KiyahBlackmon<br />

Mianonnie' Brown<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title<br />

Agency Title School District<br />

This <strong>In</strong>formation is the basis for paymentto this school district offederal funds under the ImpactAid Program (TitleVIII of the Elementaryand SecondaryEducationAct).<br />

This form must be signed and dated for this school district to receive funds based on this information.<br />

4/4/1998<br />

12/2/1994<br />

4<br />

7


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003044 Address: 1037 62ND ST<br />

(1) . (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Dateof Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

SHENEOA HART<br />

DARLENE YORK<br />

1037 62nd St #1 0<br />

1037 62nd St #5<br />

Number Students At This Property 2<br />

This Is to certify that the information shown under columns (4) and (S)<br />

ofthe foregoing sheet{s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

YES I NO YES I NO<br />

x<br />

X<br />

Dae'Zhanay Daniel<br />

D'Shi-Dnieiee Hodges<br />

This is to certify that the information shown under columns (4) and (S)<br />

ofthe foregoing sheet{s) Is correclfor the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature<br />

Date<br />

Title Agency Title School District<br />

11/15/1999<br />

This information Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.<br />

1/26/1992<br />

3<br />

9


TUTO<br />

LATANIA PARKS<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003045 Address: 3228 LOGAN ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked On Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

3228 Logan St 114<br />

3228 LOGAN ST #3<br />

Number Students At This Property 2<br />

This Is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

YES I NO YES I NO<br />

x<br />

X<br />

Tram Huynh<br />

Erika Roberson<br />

This Is to certify that the information shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature<br />

Date<br />

Title Agency TItle School District<br />

4/2811995<br />

8/2811990<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.<br />

7<br />

11


Signature<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003046 Address: 676 FAIRMOUNT AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

ParentiGuardian's ParentiGuardian's Branch of Service ParentiGuardian ParentiGuardian Name of Pupil Living With Pupil's Pupil's<br />

- Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) ParentiGuardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above properly above properly<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Francine EdwardslWayne Ryals 676 Fairmount Ave #F X Karmeisha Edwards-Ryals 3/13/1992 9<br />

RUTH LOCKE/LEO SMITH 676 FAIRMOUNT AVE #0 X Elyse Smith 6/22/1992 9<br />

FRANCINE EDWARDS 676 Fairmount Ave #F X Kalisha Williams 8/14/1997 5<br />

FRANCINE EDWARDS 676 Fairmount Ave #F X Larry Williams 5/1/1994 7<br />

Number Students At This Property 4<br />

This Is to certify that the information shown under columns (4) and (5)<br />

olthe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Tille<br />

Date Signature<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Agency Title<br />

School District<br />

This information Is the basis for payment to this school district of federal funds under the Impact Aid Program (Tille VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.<br />

Date


,-------------------------_._------


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

FederalProperty: CA003047 Address: 56529TH ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

LINDA COLEMAN 565 29TH ST #5 X Dinisha Adair 4/1/1991 10<br />

Mladie Thomas 725 39th St #5 X Ayanna Alexander 2/6/2001 1<br />

RHONOA RICHMOND 2961 Geor9ia St #1 X Unique Aubrey 5/15/1996 4<br />

TAURA HOUSTON 2527 21ST AVE #4 X Aaron Barfield 12/2/1998 4<br />

Andrea Andrade 421 Oakland Ave #5 X Adriane Beech 7/11/1990 11<br />

Katherine Bradford/Jackie Robin 7950 Ney Ave #2 X Deanthony Bradford 10/16/1990 11<br />

Latasha Barker 2425 94th Ave #2 X Shankiqua Bradsher 9/26/1993 8<br />

TAMIKA DAVIS 421 OAKLAND AVE #1 X Dejon Brantfey 2/1/1994 7<br />

TAMIKA DAVIS 421 OAKLAND AVE #1 X Marwaun Brantley 1/17/1996 6<br />

TAMIKA DAVIS 421 OAKLAND AVE #1 X Michael Brantley 101711992 9<br />

Arenia McCann/Philip Galuya 5120 Shafter Ave #4 X A1leahcaluya 12/2211998 3<br />

SARAH CARR 880 45th St #1 X Joshua carr 6/21/1996 6<br />

WATUTA WESTBROOK 421 OAKLAND AVE #3 X Bryce Clay 10/9/1992 10<br />

LAVETTE CARNEGIE 624 Ap9ar St #1 X Raymond Coopwood 3/16/1994 8<br />

This is to certify that the infonnation shown under columns (4) and (5) This is to certify that the infonnation shown under columns (4) and (5)<br />

of the foregoing sheet{s) is correct for the person listed under Column (1) ofthe foregoing sheet(s) is conrect for the person listed under Column (1)<br />

on the SURVeydate. on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title School District<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This fonn must be signed and dated for this school distric~t to receive funds based on this infonnation.


,---------------


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003047 Address: 56529TH ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Wanda Stallings 630 Apgar St #4 X Roshawn Crenshaw 9/17/1990 10<br />

Oanesha Lindsey 725 39th St #3 X Keymari Davis 4/18/1997 3<br />

KATHERINE BRADFORD/ELY 7950 Ney Ave #2 X Keirra Ely 5/17/1995 7<br />

MARIA ESCUDERO 5625 CANNING ST #12 X Dominique Escudero 10/611989 11<br />

Khrystal Gomes/Macarie Ford 565 29th St #4 X Spencer Graham 8/30/1998 4<br />

Daneshia Powell 933 46th St #5 X Deja Gresham 6/9/1997 5<br />

MONIQUE GUITON 5625 CANNING ST #9 X Connectis Guiton Jr 2/12/1991 11<br />

D. Hardiman 2425 94th Ave #3 X Asia Hardiman 3/5/2001 1<br />

REGINA ANDERSON 2425 94TH AVE #4 X Sherry Harvey 3/1/1993 8<br />

JANICEE HAWKINS 2425 94TH AVE #1 X Janeisha Hawkins 1/14/1996 6<br />

JANICEE HAWKINS 2425 94lh Ave #1 X Kenneisha Hawkins 612/1991 10<br />

LYDIA HANKINS 2527 21s1 Ave #1 X Oe'Janee Heard 3/30/1995 6<br />

Corey Hunter/ALETA STOWER 880 45th St #1 X Dante Hunter 2/5/1990 12<br />

TOM IEMNOUCHENG KOU 565 29th st #7 X Kevin lem 4/21/1996 6<br />

This is to certify that the information shown under columns (4) and (5) This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1) of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title School District<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.<br />

- -


--------------------------~


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

FederalProperty: CA003047 Address: 56529TH 8T<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

TMAIKA DAVIS 421 OAKLAND AVE #1 X Areiana Johnson 612211997 5<br />

Da'Nesha lindsey 725 39th St #2 X Donnie Jones 619/1993 9<br />

LETICIA DRAUGHTY 421 Oakland Ave #6 X ChynnaKeys 8/6/1997 5<br />

LETICIA DRAUGHTY 421 Oakland Ave #6 X Ronald Keys 10/1311991 11<br />

Danesha lindsey/Antonio Jones 725 39th St #2 X Deaunte Killingsworth 5/19/2002 0<br />

TRACY KINNICK/Christopher Fr 1449 73rd Ave #2 X Dazhana Kinnick 3/4/1994 8<br />

Tracy Kinnick 1449 73rd Ave #2 X Dian Kinnick 11/27/1990 10<br />

DANESHA POWELL 933 46TH ST #5 X Jasmine lane 211611992 9<br />

Aleisha Washin9ton 725 39TH ST #5 X A'Lazia Lewis 8/19/1999 3<br />

ARENIA C. MCCANNIPHILIP C 5120 Shafter Ave #4 X Jermaine McCann 1/24/1996 6<br />

PATRICIA NASH 880 45TH ST #2 X Joshua Nash 10/211992 9<br />

LE RHEA O'NEAL 5825 CANNING ST #7 X Nahjee O'Neal 4/14/1998 4<br />

LATASHA BARKER 2425 94TH AVE #2 X Diante Patterson 5/5/1992 9<br />

Essie Broomfield 7950 Ney Ave #1 X Robert Powell 21312001 0<br />

This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column j1)<br />

on the survey date.<br />

This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Tille<br />

School District<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This fonn must be signed and dated for this school district to receive funds based on this <strong>In</strong>fonnation.<br />

- .


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Properly: CA003047 Address: 56529TH ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

APRIL M. DURIO 421 OAKLAND AVE #6 X Oayshon Preston 2/17/1993 8<br />

TAMIKAlTRINA RICHARDSON 421 OAKLAND AVE #1 X Tyrone Richardson 6/13/1991 10<br />

CONCEPCION CERNA 881 41st SI #C X Alexander Rico 5/11/1991 9<br />

CONCEPCION CERNA 881 41st SI #C X Rosa Rico 4/2711990 12<br />

THANG SAINGPhaia Ouk 541 29th SI #2 X <strong>No</strong>ra Saing 1/14/1992 10<br />

TAMERACURRINGTON 5120 Shafter Ave #6 X Shannon Scott 1/5/1995 6<br />

SARAH CARR 880 45th SI #1 ·X Quinton Shealey 4/13/1998 4<br />

CYNTHIA COLLINS 565 29TH ST #1 X Andre Smith 9/15/1994 8<br />

CYNTHIA COLLINS/John Jacks 565 29TH ST #1 X Askari Smith 6/13/1996 6<br />

ROZETTA MCCLENDON 541 29TH ST #4 X Desmond SulVine 4/9/1998 4<br />

KENYA MITCHELL 7950 NEY AVE #10 X Kenneth Temple 10/9/1993 8<br />

BARESA BARFIELD 5825 CANNING ST #1 X De'Quan Valentine 11/29/1995 6<br />

HOANGVO 5825 CANNING ST #14 X PhuongVo 2/3/1991 11<br />

HOANGVO 5825 CANNING ST #14 X PhuongVo 2/3/1991 11<br />

This is to certify that the information shown under columns (4) and (5) This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheel{s) is correct for the person listed under Column (1) of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature Date<br />

Signature Date<br />

Title Agency Tille School District<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This fonn must be signed and dated for this school district to receive funds based on this infonnation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

FederalProperty: CA003047 Address: 565 29TH 8T<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

LAKISHA HINES 4118 Lyon Ave #204 X Antione Walker 5/24/1995 6<br />

SCHANIA HUNTER 880 45th 5t #1 X Jessica Ward 11/12/1991 10<br />

Luegenia Weathers 5825 CANNING ST #10 X Slanisha Weathers 7/10/1992 9<br />

Jacqueline Trotter/ JemmyWilso 881 41ST ST #B X Jamika Wilson 8/21/1996 6<br />

JACQUELINE TROTTER 881 41ST ST #B X Jimmy Wilson Jr 1/19/1991 11<br />

Number Students At This Property 61<br />

This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature<br />

Date<br />

Title Agency Title<br />

School District<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.<br />

- -


-----


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003048 Address: 2329 85TH AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

DEBRA REDWOOD 2329 85TH AVE #1 x Shan!ta Ratcliff 10/5/1990 10<br />

Number Students At This Property 1<br />

This Is to certify that the <strong>In</strong>fonnation shown under columns (4) and (5)<br />

oflhe foregoing sheet(s) Is correctfor the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title Agency<br />

This Is to certify that the <strong>In</strong>fonnation shown under columns (4) and (5)<br />

oflhe foregoing sheet(s) Is correctfor the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Title School District<br />

This <strong>In</strong>fonnallon Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

Federal Property: CA003050 Address: 1853 38TH AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES 'r NO<br />

RHONDA WILEY 1853 38th AVE #8 X Hykeem Andrews 3/11/1992 10<br />

LINDA JOHNSON 2820 35TH AVE #10 X Datoine Attaway 8/24/1997 3<br />

LASHANDAJACKSON 2311 98TH AVE #4 X Stajia Benjamin 5/8/1999 3<br />

Pamelyn Bickham 2820 35TH AVE #1 X Adrienna Bickham 7/5/1991 10<br />

Ashley Gonzalez/Brown, <strong>No</strong>ah 2820 35th Ave #13 X Jeremiah Brown 9/21/2002 0<br />

KiVA PORTLOCK & JAMEL BR 1430 SEMINARY AVE #7 X Jamaliah Brown Jr 10/31/1996 6<br />

KAREN SHIVERS 3330 72nd Ave #2 X Serenity Butler 11/20/1996 6<br />

DONALDILASHANDA CAMPBE 1853 38TH AVE #3 X Deshawn Campbell 1/25/1996 6<br />

Danielle Paxton 1853 38th Ave #15 X Patrick Coleman 10/26/1992 9<br />

YOLANDA WILLIAMS 2820 35TH AVE #3 X Jamelle Corbino 7/22/1993 8<br />

Yu Li Li I Jian Zhuang Wu 1853 38th Ave #12 X Jie Ylng Wu Dang 6/15/2001 1<br />

LISA PAGE 2309 98TH AVE #4 X Ha'Keila Fontenette 8/1/1995 7<br />

LISA PAGE 2309 98TH AVE #4 X Xillia Fontenette 11/29/1993 8<br />

TARAH GOODWIN 1430 SEMINARY AVE #8 X Brtttney Goodwin 4/6/1998 4<br />

This is to certify that the information shown under coiumns (4) and (5)<br />

ofthe foregoing sheet(s) is correcttor the person listed under Column (1)<br />

on the survey date.<br />

This Is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date<br />

Signature Date<br />

Title Agency Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003050 Address: 1853 38TH AVE<br />

(1) (2) (3) (4) (5) (6) (7) (S)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

ARLIS GORDON 3330 72ND AVE #7 X Cameron Gordon 3/25/1992 9<br />

Rose Marie Sally 2311 98th Ave #1 X Rodney Greene 5/612000 2<br />

RITA CHILDS 1853 38TH AVE #3 X Julian Hamilton 2/17/1998 4<br />

DanishalMario Hodge 3330 72nd Ave #6 X Marisha Hodge 8/27/1990 12<br />

Brandy Beals 1853 38th Ave #7 X Davonna Hodges 1/10/2001 1<br />

BRANDY BEALS 1853 38th Ave #7 X Derionna Hodges 12/4/1997 4<br />

Myeasha Lewis 3350 72nd Ave #2 X Damijahnique Hunt 2/16/2001 1<br />

Linda Johnson 2820 35th Ave #10 X Da'Juan Johnson 4/27/1993 9<br />

TERRI COLLINS 2820 35TH AVE #5 X Precious Jones 2/25/1994 8<br />

RITA CHILDS 1853 38TH AVE #3 X Shakira Latin 5/12/1994 8<br />

TERESA HERNANDEZ 2820 35th Ave #14 X laura Lozano 2/18/1992 10<br />

YOLANDA WILLIAMS 2820 35th Ave #3 X lrnari Lyons 6/26/1992 10<br />

Rose Sally Porter 2311 98th Ave #1 X Rodneshia Manning 12/27/1998 3<br />

YOLANDA COX 2820 35th Ave #4 X Orlando McFadden 2/17/1992 10<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5) This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correctfor the person listed under Column (1) of the foregoing sheet!s) Is correct for the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature<br />

Title Agency<br />

Date Signature Date<br />

Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003050 Address: 1853 38TH AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above properly above properly<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES T NO<br />

ANTOINETTE ABRAHAM 2126 HIGH ST #4 X Deangelo Miles 8116/1991 9<br />

Lei Logan/Johnny Logan 1853 38th Ave #13 X Johnny Om 3/11/2001 1<br />

JUDITH NAMOKI 3330 72ND AVE #5 X Derrel Rainey 6/17/1992 10<br />

JUDITH NAMOKI 3330 72ND AVE #5 X Trevon Rainey 11/9/1993 9<br />

Liew Sio Saephan 1853 38th Ave #5 X Nathan Saephanh 3/3/1991 11<br />

VICTOR SANDIFER 3330 72nd Ave #7 X Victor Sandifer Jr 3/811990 12<br />

Terry Spears 3330 72nd Ave #4 X Siquasha Simmons 8/27/1992 9<br />

TERRY SPEARS 3330 72ND AVE #4 X Tajane'E Simmons 12125/1990 12<br />

Lacena Jackson 2820 35th Ave #9 X Deven Smith 5/9/2001 1<br />

Tanesha Bordley 3330 72nd Ave #8 X Tajuana Smith 41711992 9<br />

James Thomas 2126 High St#1 X Giovanna Thomas 4/9/2001 1<br />

Marshae Lovely 3350 72ND AVE #4 X Allyah Thrower 1214/1997 4<br />

MARSHA LOVELY 3350 72ND AVE #4 X Briana Thrower 101711994 8<br />

MARSHA LOVELY 3350 72ND AVE #4 X Jessie Thrower 6/29/1992 10<br />

This Is to certify that the information shown under columns (4) and (5) This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1) of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the sUNey date. on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003050 Address: 1853 38TH AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

MARSHAE LOVELY 3350 72ND AVE #4 X Miya Thrower 2/1611991 9<br />

ALICIA SPEARS 3330 72nd Ave #4 X Terry Walker 5/24/1995 7<br />

Christen McClendon 2309 98th Ave #2 X Xavion Young 4/4/1999 3<br />

Number Students At This Property 45<br />

This is to certify that the infonnalion shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Thts Is to certify that thelnfonnation shown under columns (4) and (5)<br />

of the foregoing shaet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title School District<br />

This <strong>In</strong>fonnatlon Is the basis for payment to thIs school distrIct of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003051 Address: 1465 SEMINARY AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil liVing With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

PORTIA L. MORRIS 1465 Seminary Ave #302 X Aireahn Barnett 1/27/1993 9<br />

Thilitha Smith 2005 E 21st St #104 X Destiny Brison 10/3/1998 3<br />

LASONYA JOHNSON 2005 E 21ST ST #204 X LacharBums 6/8/1990 11<br />

CARLOS DUBOSE 1465 SEMINARY AVE #102 X Carios Dubose 1/23/1992 9<br />

Lasharele Bell 2005 E 21st St#101 X Jacari Jacobs 8/23/1999 3<br />

Michelle Jordan 2005 E 21st St #202 X Le'Andrea Jordan 4/24/1991 10<br />

Marvaletta Guy 1465 Seminary Ave #102 X James Spears 4/13/1992 10<br />

LA SHARELE BELL 2005 E 21ST ST #101 X Antoine Wallace 4/9/1992 9<br />

LA SHARELE BELL 2005 E 21st St #101 X Taron Wallace 10/6/1992 9<br />

Nikki Miles 2430 E 22nd St #103 X Robert Wesley 6/512001<br />

Glenda Wilsonffhilitha Smith 2005E21stSt#104 X Charnlqua Williams 10/10/1992 9<br />

Number Students At This Property 11<br />

This is to certify that the information shown under columns (4) and (5)<br />

olthe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Agency<br />

Title<br />

School District<br />

This information Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title Viii of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003052 Address: 2325 86TH AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Milltary as of as of<br />

Government survey date survey date<br />

YES I NO YES T NO<br />

SUE JOSEPH 2325 86TH AVE #B X Dakota Biagas 91211994 8<br />

Sue Joseph 2325 86TH AVE #B X Dominique Biagas 112211996 6<br />

Mary Ramirez 2139 Seminary Ave #103 X Rico Febo 312411999 2<br />

ANGELA BALL 2139 SEMINARY AVE #205 X Alycia Filoleo 611011999 3<br />

Vanella Thomton 1815 88th Ave #C X Harinique Halcomb 1211511991 9<br />

SUE LYNCH 2325 86TH AVE #B X Deja Lynch 312411990 11<br />

TRACY KIRKENDOLL 4631 Bond St #0 X Janetria Moore 412111991 11<br />

SHETEKAJOHNSON 2925 E 22ND ST #0 X MAUSE' AH THOMPSON 411512001 1<br />

LYNETIE LAWSON 2325 86TH AVE #0 X Deandre Ward 1111511991 10<br />

Number Students At This Property 9<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

This Is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

.Slgnature Date Signature Date<br />

Title Agency Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title Viii of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003053 Address: 7107 FAVOR ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

KATHLEEN BROWN 7107 FAVOR ST #4 X Alexus Brown 2117/1995 6<br />

MUANG CHO SAECHAO 2247 E 19TH ST#4 X Farm Chao 8/11/1992 10<br />

SAN WEN SAECHAO 2247 E 19TH ST#4 X Lai Chao 12115/1993 8<br />

Viengkong Ohlthavonq-qrandmot 2247 E 19th St #3 X <strong>No</strong>elani Chithavong 10/15/2002 0<br />

KATHLEEN BROWN 7107 FAVOR ST #4 X Troy Davis 10/24/1989 11<br />

TINA DIXON 2247 E 191hSI #2 X Van Dixon 4/1211993 9<br />

Tanecka Brisbon 2440 E 21ST ST #4 X Sarah Harris 1/13/1992 9<br />

Nicole Wiley 2440 E 21ST ST #8 X Deriyan Johnson 8/18/1998 4<br />

NICOLE WILEY 2440 E 21ST ST #8 X DESIRAY JOHNSON 3/1/2001 1<br />

Vanessa Queen 7107 Favor SI #2 X Tylor Kingsbury 9f712000 2<br />

DONNA OUTING 9320 Sunnyside SI #5 X Keith Jr Livingston 12127/1989 12<br />

Taneka BrisbonlEmeryLowe 2440 E 21st SI #4 X Ashley Lowe 1211112000<br />

LATONYA GROGEN-PENNY 7107 Favor SI #3 X <strong>No</strong>raj Penny 7f711999 3<br />

MEVI (ANGIE) SAECHOW 2440 E 21ST ST #1 X EmllyPhan 12125/1990 10<br />

This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet{s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet{s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title School District<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


-----------------------------------------------------------------------------<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003053 Address: 7107 FAVORST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

Number Students At This Property 14<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (l)<br />

on the survey date.<br />

Signature<br />

Title<br />

YES I NO YES I NO<br />

This Is to certify that the information shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) is correct for the person listed under Colu",n (l)<br />

on the survey date.<br />

Date Signature Date<br />

Agency Title School District<br />

This information Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003054 Address: 2435 26TH AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Jones Shantee E 2435 26th Ave #2 X Anise Foster 1/9/2001 1<br />

LUPE GANTT O'CON 2435 26th Ave #5 X Anlssa Gantt 8/21/2000 2<br />

MARICHEL TOLENTINO/ Simeo 2435 26th Ave #5 X Jhomarie Manzano 1/28/1995 6<br />

Marichel Tolentino/Simeon Manz 2435 26th Ave #5 X Jhunnie Manzano 2/13/1999 3<br />

PATRICIA BELL 2435 26TH AVE #3 X Patricia Mitchell 9/21/1989 12<br />

Shantee Jones 2435 26th Ave #2 X Gregory Powell 1/11/1995 7<br />

Number Students At This Property 6<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

This Is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature<br />

Date<br />

Title Agency Title<br />

School District<br />

This information Is the basis for paymentto this school district offederal funds under the Impact Aid Program (TItle VIII olthe Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

Federal Properly: CA003055 Address: 3265 PRENTISS ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

ParentiGuardian's ParentiGuardian's Branch of Service ParentiGuardian ParentiGuardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) ParentiGuardian <strong>In</strong> Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

LienTran Huynh 3265 Prentiss St #B X Sophia Ho 9/18/1993 9<br />

Ulyess WalkerlYolanda Walker 2381 E 21st St #4 X Joanna Hoston 5/9/2000 2<br />

ANNIE JONES 2381 E 21ST ST #2 X Marcel Jones 7/14/1990 11<br />

BINH LE / HANGUYE LE 2381 E 21ST ST #1 X Anthony Le 8/211992 9<br />

BINH LE 2381 E 21ST ST #1 X Anna Le Nguyen 10/26/1996 6<br />

Number Students At This Property 5<br />

This is to certify that the infonnation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correclfor the person listed under Column (1)<br />

on the survey date.<br />

This is to certify that the infonnation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title School District<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This fonn must be signed and dated for this school district to receive funds based on this infonnation.


...---------------------------------------


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003056 Address: 9024 CHERRY ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) in Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

VALARIE BELCHER 9024 Cherry St #3 X Jaleesa Belcher 8/9/1990 12<br />

ROBIN ANDERSON 2102 E 17TH ST #A X Kenneisha Caston 6/2211990 12<br />

Antoinette Holland 972 61st St #3 X Akilah Chase 1212211993 8<br />

FEN LI HE/David Choi 1951 E 24th St #1 X Michael Choi 9/25/1993 8<br />

Li Feg He 1951 E 24th St #1 X Steven Choi 10/23/2000 2<br />

David/Lily Choi 1951 E 24th St #1 X Stewart Chol 10/23/2000 2<br />

RHONDA CLARKI john murphy 9220 sunnyside st #6 X Jose Clark 6/15/1993 8<br />

!


-----------------


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

FederalProperty: CA003056 Address: 9024 CHERRY ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) in Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

YAO KOUEI LEE 2353 E 24TH ST #2 X . Chan Lua Lee 3110/1991 11<br />

ISALUCAS 1951 E 24TH ST #4 X Isaiah Lucas 5/15/1997 4<br />

ODESSIA MATTHEWS(GUARD 1737 E 15TH ST #3 X Tiarra Matthews 5/18/1992 9<br />

JENNY NGO 1944 16TH AVE #1 X Connie Ngo 7/30/1990 12<br />

HOLLYDAO 2017 E 24th St #1 X Trung Due Nguyen 4/23/1993 9<br />

SIPHEAPEAV 1737 E 15TH ST #2 X AbellonaOuk 9/211990 12<br />

SOPHA PHOUNG 1930 16TH AVE #2 X Daliya Phikun 11/18/1996 6<br />

Wilkes, Erin 2017 E 24th St #2 X Malik Riser 9/26/1995 7<br />

Deborah Rice 2353 E 24th St #3 X Fatimah Shahid 1/812001 1<br />

Deborah Rice 2353 E 24th St #3 X Muhammad Shahid 6/211998 3<br />

KEYONA HARDEN 1936 16TH AVE #1 X Isane Smith 7/14/1999 2<br />

Saran Vann 1936 16th Ave #3 X Annie Sou 8/16/2002 0<br />

Robin AndersonlRobert TIpton 2102 E 17th St #A X Kyra Tipton 3119/2002 0<br />

MESHA BRADFORD 1737 E 15th St #5 X Aaron Turner 5/11/1992 10<br />

This is to certify that the information shown under columns (4) and (5)<br />

oflhe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

oflhe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the sUlVey date.<br />

Signature Date Signature Date<br />

Title Agency<br />

Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


._--


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003056 Address: 9024 CHERRY ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

SARAHVANN 1936 16th Ave #3 X Karen Vann 2/6/1996 6<br />

Laqueta Richards 4903 Congress Ave #2 X Tylron Williams 12/21/1994 7<br />

Latonya Nicole Perkins 2102 E 17th st #C X AnnonlWise 9/1/2001 1<br />

Number Students At This Property 31<br />

This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) is correclfor the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title School District<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


-----------------------------~


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

Federal Property: CA003057 Address: 3634 FOOTHILL BLVD<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil liVing With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

MOHAMED AL-JUNAIDI 3634 FOOTHILL BLVD #9 X Hayta AI Junaidi 2128/1991 12<br />

MOHAMED AL JUNAIDI 3634 FOOTHILL BLVD #9 X iIIet AI Junaidi 4/18/1998 4<br />

SONYA JOSEPH 3634 FOOTHILL BLVD #11 X Deleshia Anders 12121/1989 12<br />

Hana Nicole Ard 3634 Foothill Blvd #16 X Iris Ard 1/2812001<br />

SHELLEY L.ARMOND 3634 FOOTHiLL BLVD #6 X Alvin Bashful 9/14/1991 11<br />

Shelley L. Armond 3634 Foothill Blvd #6 X Anjanette Bashful 6/29/1993 9<br />

LORENA BERRIOS 3634 FOOTHILL BLVD #6 X Emily Berrios 11/29/1999 3<br />

CASANDRA CRAWFORD 3634 FOOTHILL BLVD #4 X Cameran Branch 7/28/1991 11<br />

Casandra Crawford 3634 Foothiil Blvd #4 X Delarrian Branch 7/21/1994 8<br />

LATOSHA RICHARDSON 3634 FOOTHiLL BLVD #7 X Ronald Johnson 3/16/1990 11<br />

CASSANDRA CRAWFORD 3634 FOOTHILL BLVD #4 X Kiera Kidd 8/15/1997 5<br />

LATOSHA Kenard 3634 Foothill Bivd #7 X Anthony Mari9ny 8/2211997 5<br />

Latosha Kenard 3634 Foothill Blvd #7 X Antoine Marigny 10/1/1998 4<br />

GIDEON MEKWUNYE 3634 FOOTHILL BLVD #1 X Gideon Mekwunye 11/27/1995 7<br />

This Is to certify that the information shown under columns (4) and (5) This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1) of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature<br />

Date Signature Date<br />

Title Agency<br />

Title School District<br />

This <strong>In</strong>formation is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003057 Address: 3634 FOOTHILL BLVD<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if appilcable) i1ved on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as at as at<br />

Government survey date survey date<br />

Tuyet Nguyen<br />

LATOSHA Kenard<br />

May Saephan<br />

3634 Foothill Blvd #5<br />

3634 Foothill Blvd #7<br />

3634 Foothill Blvd #10<br />

Number Students At This Property 17<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the sURVey date.<br />

Signature<br />

YES I NO YES I NO<br />

x<br />

X<br />

X<br />

Ha Nguyen<br />

Jahleel Phillips<br />

Doneathan Saephan<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet{s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Title Agency Title<br />

School District<br />

10/1711992<br />

7/8/1994<br />

6/20/1995<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.<br />

10<br />

8<br />

7


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003058 Address: 7510 NEY AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

ARETHA CARON HARRIS 7510 NEY AVE #B X DALLAS BAKER JR 8/26/1990 10<br />

Kenya Smith-Edwards 6650 Laird Ave #D X Mario Edwards Jr 11/1011997 5<br />

Mul Chuong 6650 Laird Ave #C X Jackie Nguyen 4/13/2001 1<br />

SHARLENA RICHARDSON 7510 NEY AVE #E X Mark Richardson 9/29/1990 12<br />

Tammie Rivera 6656 Laird Ave #B X Curtis Smith Jr 4/21/1998 4<br />

Ganya Taylor 7520 NEY AVE #A X Cameron Taylor 3/3/1999 3<br />

JESSIFER JOHNSON 7520 NEY AVE #D X Jacqueline Webster 6/1111998 3<br />

Number Students At This Property 7<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Title Ageney Title<br />

School District<br />

This <strong>In</strong>formation is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003059 Address: 368 62ND ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Nemarsha Jack 368 62ND ST 115 X Charles Anderson 1/1/1998 3<br />

NNEMARSHAJACK 368 62ND ST 115 X Kapree Anderson 12/2/1999 2<br />

SABRINA VALLIER 368 62ND ST #4 X Dasja Bates 12/9/1992 10<br />

SABRINA VALLIER 368 62ND ST #4 X Eric Bates 7/1111990 11<br />

MONIQUE BELL 3000 E 18TH ST#6 X Hassani Bell 10/17/1997 5<br />

Cornelius/Helen Bracken 1500 38th Ave #1 X Myaisha Bracken 9115/1991 11<br />

Maurlce & Jaoklshala Bright 9703 Cherry St #2 X Maurice Bright Jr 4/24/2002 0<br />

PRISCILLA GARCIA 1120 BELLA VISTA AVE #3 X Angelena Brissolese 9/20/1996 5<br />

Priscilla Garcia 1120 Bella Vista Ave #3 X Cerena Brissolese 1/19/2000 2<br />

CLAYTON, MYRTIS BUTTRAM 2228 48TH AVE #5 X Calijah Buttram 5/9/1999 3<br />

MYRTIS BUTTRAM 2228 48TH AVE #5 X Clayton Buttram 11/9/1997 5<br />

Buttram, Myrtis/Buttram Jr., Clay 2228 48th Ave 115 X Kalaysia Buttram 9/24/2002 0<br />

Janet Clark 1726 38th Ave #3 X Lavante Cervantes 7/1/1994 7<br />

CHARLA GARY/M. Collins 368 62ND ST 115 X MARYAH COLLINS 6/2612002 0<br />

This Is to certify that the inlonmation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

This is to certify that the infonmatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency<br />

Title School District<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003059 Address: 368 62ND ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With, Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

CHARLA GARY/M. Collins 368 62nd St #5 X Marcus Collins Jr 11/9/1998 4<br />

BARBARA CURTIS 9506 BIRCH ST #3 X Soliel Curtis 9/24/1992 10<br />

Helen Brackens 1500 38th Ave #1 X Millian S Davis 2115/1990 11<br />

TERESA YORK 1120 BELLA VISTA AVE #2 X Lattesha Dove 1/24/1990 11<br />

Lulu EI 9508 Birch St #5 X NajiaEI 8/29/1996 6<br />

Nia Finley 1500 38th ave #4 X Tra'Von Finley 9/27/1991 11<br />

Gevelle Johnson 4737 Ygnacio Ave #6 X Tajanee Ford 10/1211992 9<br />

GEVELLE JOHNSON 4737 YGNACIO AVE #6 X Tajanique Ford 10/6/1993 7<br />

GEVELLE JOHNSON 4737 YGNACIO AVE #6 X Toby Ford 9/18/1995 5<br />

GEVELLE JOHNSON 4737 YGNACIO AVE #6 X Tyquese Ford 10/25/1998 4<br />

LaTanya Ashley 1928 96th Ave #4 X Roshanda Goodwin 2124/1991 10<br />

JANELLE FLOWERS 368 62ND ST #1 X Darian Gordon 2114/1999 3<br />

JADELLE FLOWERS 368 62ND ST #1 X Darrell Gordon 6f711997 4<br />

Maria Cabrera 368 62nd St #2 X Jasmin Lopez 9/27/1998 4<br />

This is to certify that the information shown under columns (4) and (5) This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correctlor the person listed under Column (1) olthe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature Date<br />

Signature Date<br />

Title Agency Title School District<br />

This information Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003059 Address: 368 62ND ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Govemment survey date survey date<br />

YES I NO YES I NO<br />

ROSIE MCDONALD 4737 YGNACIO AVE #4 X Kmahjaney Mcdonald 3/16/1999 3<br />

Rosie McDonald 4737 Ygnacio Ave #4 X Sania McDonald 6/18/2000 2<br />

ZINAMURRAY 9514 BIRCH ST #4 X Ra'Shawn Murray 1/1911990 12<br />

Taquoise Newberry 4737 Ygnacio Ave #3 X La'Ray Oliver 11/18/1999 3<br />

Taquoise Monique Newberry 4737 Ygnacio Ave #3 X Larissa Oliver 1211/2001 1<br />

Taquoise Newberry 4737 Ygnacio Ave #3 X Larry Oliver 9/811998 4<br />

Barbara 9506 Birch St #3 X Semaj Penn 4/23/2000 2<br />

LESSIE M PHILLIPS 9703 Cherry St #4 X Dealra Phillips 5/27/1990 11<br />

SHONTE RICHARDSON 3000 E 18TH ST #4 X Frederick Roberson 8/25/1995 7<br />

LATANYA ASHLEY 1928 96TH AVE #4 X Sherrell Starks 101711995 6<br />

Kinya Malone 1120 Bella Vista Ave #2 X Kamran Stephens 1/21/2000 2<br />

KINYA MALONE 1120 Bella Vista Ave #2 X Kevin Stephens Jr 2121/1995 7<br />

LOANTRAN 3000 E 18th St #3 X Jamie Tran 6/21/1994 7<br />

Bessie Dixon/Alkaya Green 3000 E 18th St #2 X Marlreca West 9/28/1994 8<br />

This Is to certify that the information shown under columns (4) and (5) This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person nsted under Column (1) of the foregoing sheet(s) Is correct for the person nsted under Column (1)<br />

on the survey date. on the survey date.<br />

Signature<br />

Title Agency<br />

Date Signature Date<br />

Title School District<br />

This information Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003059 Address: 368 62ND ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

Number Students At This Property 42<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

YES I NO YES I NO<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency<br />

Title<br />

School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003060 Address: 5018 MELROSE AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) in Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Nagla Mohamed 5018 Melrose Ave #4 X Adham Alaskan 12126/1996 5<br />

NAGLA MOHAMED 5018 MELROSE AVE #4 X ASHRAF ALASKARI 218/2002 0<br />

Nagla Mohamed 5018 Melrose Ave #4 X Mariam Alaskan 12129/1999 2<br />

NAGLA MOHAMED 5018 Melrose Ave #4 X Adam AI-Askari 6/24/1995 7<br />

CHARLES BROWN/Charleta Wil 5018 Melrose Ave #3 X Atika Brown 10/8/1990 10<br />

MARIA LETICIA LEPE 2181 48TH AVE #C X Christian Camacho 12126/1996 5<br />

Constance Jordan 2181 48th Ave #B X Jessica Hargrove 7/29/1992 9<br />

JULIA TAYLOR 869 WALKER AVE #2 X Julia Jones 6/4/1996 6<br />

ANASTASIA PIPKIN 869 WALKER AVE #3 X Michael Jones 1/6/1991 10<br />

Van MailThi Trang 5250 Ygnacio Ave #2 X ThoMai 1/18/1991 11<br />

TRANG THI KIEU TO 5250 YGNACIO AVE #2 X Tony Mal 3/20/1994 8<br />

TRANGT. TO 5250 YGNACIO AVE #2 X John To 9/2I1997 4<br />

Number Students At This Property 12<br />

This Is to certify that the <strong>In</strong>fonnatlon shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

This Is to certify that the <strong>In</strong>fonnation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature<br />

Date<br />

Title Agency Title School District<br />

This <strong>In</strong>fonnation is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

Federal Properly: CA003061 Address: 5945 BROMLEY AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

LaShawn Thompson 5945 Bromley Ave #D X Charles Brown 7/10/1998 4<br />

GLADYS ASHLEY 5945 Bromley Ave #D X Dominique Brown 5/7/1992 10<br />

GLADYS ASHLEY & ANTHONY 5945 BROMLEY AVE #D X Anthony Coleman Jr 814/1994 7<br />

GLADYS ASHLEY 5945 Bromley Ave #D X Davalle Davis 2/2/1991 9<br />

Teana Bass/Johnell Henley 5945 Bromley Ave #A X Johnell Henley Jr 10/24/2001 1<br />

GRANT CARR 5945 BROMLEY AVE #A X DaiJ'on Ross 6/2/1994 8<br />

Number Students At This Property 6<br />

This Is to certify that the <strong>In</strong>fonnation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

This is to certify that the <strong>In</strong>fonnation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature<br />

Date<br />

Title Agency Title School District<br />

This <strong>In</strong>fonnation Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003062 Address: 920 62ND ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

ParentiGuardlan's ParentiGuardian's Branch of Service ParentiGuardlan ParentiGuardlan Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) ParentiGuardian <strong>In</strong> Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

CHRISTIYA TAYLOR 920 62ND ST #1 X Christopher Alsobrook 5/27/1991 10<br />

Renata Hancock 357 49th St #6 X Reniah Baker 1/25/2000 2<br />

CASSANDRA BARRANCO 3017 WEST ST #3 X Qulsan Barranco 7/27/1998 4<br />

Jeanette Blackmon 357 49th St #4 X Oareion Blackmon 4/15/2001 1<br />

Can Bolling 920 62nd St #3 X Deonle Bolling 217/1996 5<br />

TAMEISHA O'GUINN 365 49TH ST #8 X Rossaun Bowser 7/16/1999 3<br />

Daniel Broadnax/ALEXIS HALU 3017 WEST ST #2 X Porsha Broadnax 3/20/1995 6<br />

TONYA D. WILSON 365 49TH ST #5 X Keniard Bull 8/16/1991 11<br />

ALMATEEN TWEEDIE 648 57TH ST #4 X James Bums 12/2/1992 9<br />

LATOSHIA HUDSON 3017 West St #7 X Dreamius Cosby Jr 9/10/1990 11<br />

STARLET ROBINSON 365 49TH ST #6 X Jamaila Davis 6/5/1991 10<br />

Saundra Dickens 5805 Canning St #3 X Sean Dickens 5/5/1993 9<br />

ClARA LEWIS 365 49TH ST #3 X Damaglo Garrison 217/1998 4<br />

Starlet Robinson 365 49th St #6 X Dereck Gordon 1/24/1999 3<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5) This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correct for the person listed under Column (1) of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title School District<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


,,-------------


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003062 Address: 920 62ND ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

KIMBERLY CASEY 365 49TH ST #4 X Ira Haley 6/6/1998 4<br />

JUANITA LIPSEY 5805 CANNING ST #3 X Diamond Hardaway 6/12/1993 9<br />

SEBRENA FLENNAUGH 361 49TH ST #2 X James Hines IV 3/5/1996 6<br />

SEBERENA FLENNAUGH 361 49TH ST #2 X Kejaney Johnson 1/31/1993 10<br />

ELIZABETH LEE 648 57TH ST #5 X VyLe 8/111993 9<br />

Anne Lavonne Amons 365 49th St #1 X Deonta Martin 7/7/1991 11<br />

Cassandra Barranlo 3017 West St #3 X Valleesha Matthews 5/17/2001 1<br />

BETTY JOHNSON 2995 School St #5 X Tatyana Mccoy 11/12/1994 8<br />

ALEISHA WASHINGTON 3025 MARTIN LUTHER KING J X Calvin McRay 1/24/1995 7<br />

STARLET ROBINSON 365 49TH ST #6 X Dashanea Morrow 1/21/1994 8<br />

STARTLET ROBINSON 365 49TH ST #6 X Deserea Morrow 1/21/1994 7<br />

Sebrena Flennaugh 361 49th St #2 X Delvahn Mosley-Davis 8/24/1994 7<br />

CHERICE EARBY 365 49Jh St #4 X Kennedy Mullins 2/6/1992 10<br />

KAYASIBLEY 4516 Fairfax Ave #1 X Dureana Murphy 6/16/1995 7<br />

This Is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency<br />

Title School District<br />

This <strong>In</strong>formation is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


.... -


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

Federal Property: CA003062 Address: 920 62ND ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

GAIL COTTON 357 49TH ST #5 X Ashley Neal 111711998 4<br />

TAMEISHA O'GUINN 365 49TH ST #8 X Tanika O'Guinn 1/13/1994 8<br />

Josephine/Louisa Padilla 2995 School St #1 X Sanflaqo Padilla 12123/2000 1<br />

Josephine/Louisa Padilla 2995 School St #1 X Analieia Padilla Castro 5/6/1998 4<br />

Louisa Padilla/Josephine Padilla 2995 School St #1 X Sarafina Padilla-Newton 4/16/1995 7<br />

PAMELA CASEY 920 62ND ST #2 X Latrice Roddy 5116/1990 10<br />

DIEDRA ROGERS 3017 WEST ST #8 X Akira Rodgers 5/25/1999 3<br />

LEWIS ClARA RAESHAWN 365 49TH ST #3 X SIERECE SHERMAN 11/26/2001 1<br />

Brandy Thomas 1039 63RD ST #3 X Aman Singh 8/5/1998 3<br />

Brandy Singh 1039 63rd St #3 X Samar Singh 9/212000 2<br />

Felicia Jones 2995 School St #2 X Tyrell Smith 3/24/1992 9<br />

Angelica Williams 648 57th St #3 X Zyrnariae Smith 5/9/2002 0<br />

GLORIA SMITH 1039 63rd St #4 X Anthony Smith-Randall 4/11/1991 10<br />

EDWARD STEWART 4516 FAIRFAX AVE #2 X Oceanna Stewart 11/3/1997 5<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

This Is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Title Agency<br />

Title School District<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003062 Address: 920 62ND ST<br />

Signature<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

CHRISTIYA TAYLOR 920 62nd St #1 X Canington Taylor 12/13/1994 6<br />

Constance Hannibal & Lynn Rix 3017 West St #5 X Da Shawn Taylor 12/14/1996 4<br />

CONSTANCE HANNIBAL 3017 West SI #5 X Dajanne Taylor 6/14/1993 8<br />

CONSTANCE HANNIBAL 3017 West St #5 X David Taylor Jr 111111995 6<br />

Cora Wilcots/Precious Butler 3017 West SI #1 X Robbie Thompson 5/11/2002 0<br />

Warner Eland Dwan Walker 365 49th St #7 X D'Montay Warner 311812002 0<br />

RENITA WESSON-JONES 3025 Martin Luther King Jr Way X ROMERO WESSON 5/17/2001 1<br />

Anne Amons 365 49th St #1 X Ericka Wright 2/23/1993 9<br />

SAKHOEUTH YAV/KIMSORY L 680 55TH ST#A X SandyYav 10/27/1992 10<br />

Number Students At This Property 51<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Title Agency Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this school dlstrtct offederal funds under the Impact Aid Program (TItle VIII ofthe Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.<br />

Date


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003063 Address: 656 53RD ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

ROSALIND/RONALD ACOFF 666 53RD ST #8 X Shaivonne Acoff 6/5/1991 11<br />

DAVID/MACHITA SHIVERS 6309 BAKER ST #1 X Otis Andrews Jr 7/5/1996 6<br />

ANTIONETIE MONDY 594 63rd SI #2 X Gerell Arterberry 9/2/1994 8<br />

NEJRAALLEN 3217 WEST ST #4 X Cameron Bailey 1/9/1990 12<br />

Myron Moses/Nejra Allen 3217 WEST ST #4 X Devante' Bailey 5/4/1992 9<br />

DETRA ANDREWS 164481sIAve#C X Aliyah Bell 6/2/1999 3<br />

BOBBIE JACKSON 6309 BAKER ST #4 X Melvin Bell 5/1/1991 10<br />

BOBBIE JACKSON 6309 BAKER ST #4 X Shikila Bell 7/811993 9<br />

KAREN PATIERSONIALAN BO 454 36th SI #1 X Alliyah Bohlar 7/4/1995 7<br />

CASSANDRA WALKER 454 36TH ST #1 X ALYSSA BOHLAR 11/17/2001 0<br />

CASSANDRA WALKER 454 36th St #1 X Brandon Bahlar 11/20/1993 8<br />

AMANDA JONES 950 40TH ST #17 X Michael Bradford 6/7/1992 10<br />

CARLA WATSON/GERMAINE B 987 63rd SI #3 X Germaine Brown 1217/1990 10<br />

CARLA WATSON 987 63rd SI #3 X Jamil Brown 12/21/1994 7<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Title Agency<br />

This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Title School District<br />

This <strong>In</strong>formation is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Federal Property:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003063 Address: 656 53RD ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living Wilh Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Mllilary as of as of<br />

Government survey dale survey dale<br />

YES I NO YES I NO<br />

ALiCHIA CLAYTON 873 32nd SI #1 X Alicia Carter 2/18/1998 4<br />

ALiCHIA EDWARDS 873 32nd SI #1 X Damesha Carter 2/18/1998 4<br />

Juan Carios/Hortensla Caslillo 950 40th SI #4 X Juan Castillo 5/4/1991 10<br />

Hephzibah Cornish 656 53rd St #6 X Hezzekiah Coleman 4/26/2001 1<br />

Hephzibah Cornish 656 53rd sl #6 X Nehemiah Coleman 10/31/2002 0<br />

RHONDA WYNNE 3217Wes1SI#1 X QUincy Cotton 6/19/1992 9<br />

CECILIA SMITH 4520 MONTGOMERY ST #4 X Malik Couey 10/1/1990 12<br />

Alichia Clayton 873 32ND ST #1 X Miccle Edwards 11/21/1990 10<br />

Evans, Aleta 3217 West St #3 X Alexandra Evans 7/5/1999 3<br />

DELONDA DAWKINS 987 63rd St #2 X Aaron Frison 8/8/1993 9<br />

Ermelinda Godinez! Paolo Orteg 873 32nd St #4 X Berenice Godinez 1111/2002 0<br />

SABRINA GREEN 656 53RD ST#14 X Nikita Green 3/1/1990 12<br />

KEVIN TROTIER, FATHER 656 53RD ST #5 X Aujihnae Harris 5/16/1997 5<br />

Reatha LoWSIMOYA SURRELL 594 63rd St #2 X Shree Harris 2/9/1995 7<br />

This is 10 certify Ihallhe <strong>In</strong>formallon shown under columns (4) and (5)<br />

olthe foregoing sheel(s) is correcllor Ihe person Iisled under Column (1)<br />

on the survey date.<br />

This is 10 certify Ihallhe <strong>In</strong>formallon shown under columns (4) and (5)<br />

of Ihe foregoing sheel(s) Is correct for Ihe person IIsled under Column (1)<br />

on the survey date.<br />

Signature Dale Signalure Dale<br />

Tille Agency Tille<br />

School District<br />

This <strong>In</strong>formalion is Ihe basis for paymenllo Ihls school dlslrlct of federal funds under Ihe Impact Aid Program (TIlle VIII of Ihe Elemenlary and Secondary Educallon Acl).<br />

This form musl be signed and daled for Ihls school dlslrlct 10 receive furids based on this <strong>In</strong>formalion.


----------------------------


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003063 Address: 656 53RD ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil liVing With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Marian Bennetu Ramon White 873 32nd St #3 X Staranna Hogue 8/20/2000 1<br />

LATOYA LEWIS VARNEDOE 565 45TH ST #4 X CLARYCEJEFFERSON 8/5/2002 0<br />

LATOYA LEWIS VARNEDOE 565 45th St #4 X ISAIAH JEFFERSON VARNED 5/21/2001 1<br />

RACHEL MCDONALD/KEITH J 3217 WEST ST #5 X Kiyana Jones 7/15/1992 10<br />

Laronda Letishe Foster / Chartes 873 32nd St #5 X Chertsh Joseph 4/27/2001 1<br />

Christina Ferrara 987 63rd St #5 X Cordell Joseph 10/4/1990 11<br />

Rachel McDonald/Anthony McMi 3217 West St #5 X Esean Kelly 12/31/1993 7<br />

Debra George 950 40TH ST #7 X Rayshawn Lawrence 7/22/1998 3<br />

RASHONDA WILSON 873 32ND ST #7 X Da'Shawn Lee 4/23/1998 4<br />

VEATTA PHILLIPS/ANNIE PHIL 666 53RD ST #8 X Mon'ALewis 11/28/1991 10<br />

MARGIE CROSBY 6309 Baker St #3 X Jazmine Lincoln 10/11/1997 4<br />

MARGIE CROSBY 6309 Baker St #3 X Rushonda Lincoln 5110/1994 7<br />

VIRGINIA LLOYD 2308 96TH AVE #7 X Charnique Lloyd 7/2/1988 12<br />

Guadalupe-Saul Longinos 950 40th St #1 X Manuel Longinos 11/25/1999 3<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency<br />

Title School District<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003063 Address: 656 53RD ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With, Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

LATASHA LOPEZ 1644 81ST AVE #A X Joevon Lopez 8/19/1992 9<br />

CHERISE HOLMES 666 53rd SI #9 X Devonjtae Mason 5/5/1992 9<br />

Tomika McGann 987 63rd St #1 X Edward Mccann 9/2/1999 3<br />

RHONDA WYNNE 3217 WEST ST #1 X Devereaux Moore 11/4/1996 5<br />

Onelia Bell 2308 961hAve #4 X Rogel Moore 11/24/1996 6<br />

NEJRA R. ALLEN/Myron Moses 3217 WEST ST #4 X Breonna Moses 10/26/1993 9<br />

CYNTHIA NIX/Kelvin Bowers 4520 MONTGOMERY ST #1 X Jacori Nix-Bowers 4/7/1992 10<br />

Marian Bennetv Ramon White 873 32nd SI #3 X Joseph-Joaquin Palomar-Hogue 7/30/2002 0<br />

SANDRA JONES-JOHNSON 950 40TH ST #17 X Shaquilla Prosser 12/15/1992 9<br />

CHERISE HOLMES 666 53RD ST #9 X Chevonjlae Ross-Rix 4/21/1994 8<br />

ANNA HARRIS 2308 96TH AVE #2 X Billie Shelton 5/2/1991 11<br />

ANNA HARRIS 2308 96TH AVE #2 X Sabrina Shelton 7/15/1993 9<br />

MACHITA SHIVERS 6309 BAKER ST #2 X David Shivers 12/5/1997 4<br />

Delonda Lang 987 63rd SI #2 X Akeem Smith 4/12/1999 3<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

This Is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency<br />

Title School District<br />

ThiS information Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003063 Address: 656 53RD ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Delonda Lang 987 63rd St #2 X Aronnisha Smith 11/24/1996 6<br />

DELORES PAIGE 837 60TH ST #1 X Leonard Stallings 5/31/1992 10<br />

Carla Watson 987 63rd St #3 X Douglas Stephens 11/29/2000<br />

Tanzania Street 594 63rd St #4 X Zaire Street 1213/2000 1<br />

Tanlsha Ashley 873 32nd St #5 X Shacarria Tavares 10/11/1995 6<br />

PATRICIA JOHNSON 656 53RD ST #12 X Mykel Thomas 1/31/1991 9<br />

QuyTran 950 40th St#14 X Quyen Tran 9/4/1993 9<br />

BeVu 950 40TH ST #2 X Quynh Tran 6/13/1997 5<br />

VuBe 950 40TH ST #2 X Ryan Tran 3/5/1999 3<br />

Dac TranI Be Vu 950 40th St #2 X Thien Tran 31712002 0<br />

KASHAROY 3217 WEST ST #2 X Shaswanda Van Hoose 6/3/1990 12<br />

ALETA EVANS 3217 WestSt#3 X MICHAEL WALKER III 2125/2002 0<br />

ROSALYN BARKER 837 60TH ST #4 X Bruce Walton 71711993 9<br />

JEANETIE WATIS 594 63RD ST #3 X Katrina Walls 3/13/1990 12<br />

This Is to certify that the information shown under columns (4) and (5) This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1) of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature Date Signature Date<br />

Title Agency<br />

Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle Viti of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003063 Address: 65653RD ST<br />

Signature<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Margie Crosby 6309 Baker St #3 X Margertta Williams 3/1/1993 9<br />

MARGIE CROSBY 6309 Baker St #3 X Naomi Williams 2/3/1992 10<br />

Emanuel Worthington 950 40TH ST #8 X Jantelle Worthington 1/25/1992 9<br />

Number Students At This Property 73<br />

This Is to certify that the <strong>In</strong>fonnatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature<br />

This is to certify that the <strong>In</strong>fonnatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Title Agency Title School District<br />

This infonnation is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.<br />

Date


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003064 Address: 2474 26TH AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as 01<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

TAMEKA MUMPHREY 2474 26TH AVE #4 x TAVION JENKINS 8/1812002 o<br />

Number Students At This Property 1<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

TItle Agency<br />

This Is to certify that the information shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003066 Address: 1632 E 19TH ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

ABIOT ARARSO 1632 E 19th st #5 X lskander Ararso 1/1/1991 12<br />

Lydia Fields 944 34th St #2 X Thomeika Clark 3/23/1991 10<br />

RHONDA RICHMOND 5914 COLBY ST #2 X Andrianna Davis 12/13/1993 8<br />

YOLONDA THOMAS 944 34th SI #3 X Asiana Duncan 7/10/1991 10<br />

Felicia Gill/Joseph Gaylor, Jr. 578 58th SI #2 X Ja'Shonn Gaylor 1/29/2001 1<br />

BEVERLY FRANKLIN 5914 COLBY ST #6 X Lamonte Hardman 11/27/1990 10<br />

Rhonda Richmond 5914 Coiby SI #2 X Ajah Hayes 4/23/1992 9<br />

GLORIA MARIE HARRIS 584 58TH ST #9 X Yanie Henderson 5/22/1991 10<br />

GLORIA HARRIS 584 58TH ST #9 X Yohana Henderson 2/11/1994 8<br />

EBONY NOLEN 1632 E 19TH ST #1 X Amari Henry 8/5/1997 4<br />

QUEENESTHERJONES 9615 E SI #1 X Neiasha Hill 1/15/1991 10<br />

Chionna Moore 9615 E SI #3 X Khantane Jackson 3/14/2000 2<br />

ALICIA WINBUSH 584 58th SI #5 X Raquel Mills 6/18/1990 12<br />

ANGELA THOMAS 5914 COLBY ST #3 X Kamelah Mundy 7/1/1997 5<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5) This Is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1) of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature Dale Signature<br />

Date<br />

Title Agency Title<br />

School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district oHederal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


...------------------------------------------------------


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003066 Address: 1632 E 19TH ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

TERRI GRAVES 5914 COLBY ST #4 X T'Nya Payne 9/19/1997 5<br />

BO CHANG PENGlLin Yue Oin9 1632 E 19th St#6 X Shirley Pen9 10/9/1993 9<br />

BO CHANG PENGILIU YUE 01 1632 E 19th St #6 X Teresa Peng 1/27/1991 11<br />

Chionna Moore 9615 E St #3 X Khamonie Piper 8/2212001<br />

Rhonda Williams 584 58th St #10 X Jaidah Robinson 8/28/2001<br />

CHERYL HOWARD 9615 E St#5 X Leondre Stansberry 8/3/1993 8<br />

Ebony & Maurice Thomas 1632 E 19th St #1 X Kyrah Thomas 3/11/2002 0<br />

Maurice& Ebony Thomas 1632 E 19th St#l X Mariah Thomas 211212000 2<br />

FELICIA GILL 578 58th St #2 X Oeion Tucker 3/25/1991 10<br />

TRELLA WELLS 5914 COLBY ST #3 X Antwaniqua Varello 3/18/1990 12<br />

DONNELL WELLS 5914 COLBY ST #3 X Mykayla Wells 6/14/1994 8<br />

Number Students At This Property 25<br />

This Is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

This Is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title School District<br />

This <strong>In</strong>formation is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receIve funds based on this information.


----------------------------------------


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003067 Address: 2155 E 28TH ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

TAMMY MYERS 2155 E 28TH ST #5 X Deonte Bradford 1217/1991 9<br />

TAMMY MYERS 2155 E 28TH ST #5 X Dominique Bradford 5/7/1995 7<br />

TONI MYERS 2155 E 28TH ST #5 X De'Moirrea Frazier 121211990 9<br />

RUBY FREEMAN 678 29TH ST #3 X Ashley Freeman 2117/1992 10<br />

KAREN NORMAN TRAMMELL 2933 Martin Luther King Jr Way X Raven Johnson 9/10/1992 10<br />

Barbara Lewis 678 29TH ST #1 X Samuel Larkins 6/1711991 11<br />

CHERYL FRA21ERiMarkita Fraz 2155 E 28th St #5 X Jamisha Myers 6/20/1994 7<br />

CHITH KOUIYOTH 6631 LAIRD AVE #4 X Junnyrath Oeurn 6/3/1999 3<br />

CHITH KOUIYOTH 6631 LAIRD AVE #4 X Sokpharith Oeum 5/15/1998 4<br />

LATASHA WILEY 6631 LAIRD AVE #3 X Mark Simmons 4/1211997 5<br />

Lathasha Wiley 6631 Laird Ave #3 X Rhachey Simmons 3/10/1992 9<br />

KAREN NORMAN 2933 MARTIN LUTHER KING J X Skye Trammell 7/23/1997 5<br />

Elonda Warner 2155 E 28TH ST #3 X Dashantay Walker 4/26/1998 3<br />

Elonda Warner 2155 E 28th St#3 X DwonWalker 21212000 1<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5) This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) is correcltor the person listed under Column (1) of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title School District<br />

This information Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


...---------------------------------~


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003067 Address: 2155 E 28TH ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

DENITA WILLIAMS 6631 LAIRD AVE #1<br />

Denita Williams<br />

6631 Laird Ave #1<br />

Number Students At This Property 16<br />

This is to certify that the infonnation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

YES I NO YES I NO<br />

x<br />

X<br />

Raimon Williams<br />

Tiana Williams<br />

This is to certify that the infonnatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Title Agency<br />

Title School District<br />

11/18/1999<br />

This <strong>In</strong>fonnation is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.<br />

7/1/1995<br />

2<br />

7


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

FederalProperly: CA003068 Address: 5125 MARTIN LUTHER KING JR WAY<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Laquida Prall 5125 Martin Luther King Jr Way X ErishaAdams 3/18/1991 9<br />

TAWANDAJACK 5125 MARTIN LUTHER KING J X Le'Mondre Bailey 11/17/1994 8<br />

TAWANDAJACK 5125 MARTIN LUTHER KING J X Shinena Bailey 3/3/1998 4<br />

Carla Patterson 3855 Shafter Ave #3 X Delontae Bellamy 7/212000 2<br />

Sylvia Burks 2943 NICOL AVE #3 X Dalorrein Burks 7/15/1990 12<br />

Brandi Pratt 5125 Martin Luther King JrWay X Katrina Butler 4/19/1994 8<br />

Bessie Mae Barnes 5125 Martin Luther King Jr WAY X Myleke Byers 1/16/1999 3<br />

BESSIE BARNES 5125 MARTIN LUTHER KING J X Octorta Byers 5/14/1991 11<br />

VANNY LAN 1305 E 25TH ST #D X John Carson 11/19/1990 11<br />

VANY/RICHARD CARSON 1305 E25th St#D X William Carson 6/25/1992 10<br />

Yolanda Thomas 2943 Nicol Ave #5 X Danielle Dunham 3/29/1994 8<br />

Martinesha Gilberti Jabart Gilber 1305 E 25th St #B X Brtaja Gilbert 5/5/2002 0<br />

Teresa B. Kennedy 2943 Nicol Ave #5 X Jerron Grant 5/23/1997 5<br />

Henry, Eda 5125 Martin Luther King Jr Way X Lahoma Henry 7/212002 0<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) is correclfor the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Title Agency TItle School District<br />

This <strong>In</strong>formation is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003068 Address: 5125 MARTIN LUTHER KING JR WAY<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

ParentiGuardian's ParentiGuardian's Branch of Service ParentiGuardian ParentiGuardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) ParentiGuardian <strong>In</strong> Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

CARLA PATIERSON 3855 Shafter Ave #3 X Destinee Hodges 8/21/1993 8<br />

TANYA HOWARD 3855 SHAFTER AVE #4 X Quincie Howard 1/3011997 5<br />

Latreece Camp 211538thAve#3 X Ja'Monie Johnson 11/23/1998 4<br />

Camell Perry 5125 MARTIN LUTHER KING J X Zakari Perry 11110/1997 5<br />

CARNELL PERRY 5125 MARTIN LUTHER KING J X Zerenna Perry 9/7/1995 7<br />

Emerald Hallman 2943 Nicol Ave #2 X Aries Pierce 9/27/1998 6<br />

Lateesha Perkins 2110 25th Ave #2 X Linda Scruggs 7/26/2000 1<br />

ERSHELL LOVE (UNCLE) 2115 38TH AVE #1 X Latasha Smith 9/1911990 10<br />

TANYA HOWARD 3855 SHAFTER AVE #4 X JOEMARTATE 2117/2001 1<br />

Brandy West 3855 Shafter Ave #1 X LaTavia West 9/16/2000 1<br />

Number Students At This Property 24<br />

This Is to certify that the <strong>In</strong>formetlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Title Agency Title<br />

School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,·2007.<br />

Federal Property: CA003069 Address: 7000 LACEY AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With PUPil'S Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Latonya Lee/Alonzo Davis 7000 LACEY AVE #4 X David Anderson 12125/1990 11<br />

Crystal McElroy 5944 Bromley Ave #2 X I'Nice Baker 6/25/1993 8<br />

Patrice Porter 5944 Bromley Ave #2 X Travon Baker 3/25/1992 9<br />

YINGBIMAI 1424 50th Ave #4 X Muting cen 9/22/1992 9<br />

MAl, YINGBI 1424 50th Ave #4 X Xincheng Cen 4/20/1994 8<br />

MAl, YING-BI 1424 50th Ave #4 X Xin·Wei cen 4/20/1994 8<br />

ETHYL E DAVIS 3901 Webster St #13 X Darryl Cornelius 4/14/1993 7<br />

VANNY EM 5944 Bromley Ave #3 X Sotheara Em 6/11/1991 10<br />

SHUNICE WILLIAMS 7000 LACEY AVE #5 X Dedriana FaUHuey 6/11/1997 5<br />

SHUNIC WILLIAMS 7000 LACEY AVE #5 X Takuma Huey 51711997 6<br />

LAKEITHA STEWART 1730 85TH AVE #1 X Damonea Hull 10/23/1995 6<br />

JEWEL DAVENPORT 320 HADDON RD #3 X Arliton Johnson 5/1811990 10<br />

R. Morales/C. Pascua 1639 84th Ave #1 X Jenisse Morales 3/12/1999 3<br />

CAROLYN PASCUA & RA YMU 1639 84TH AVE #1 X Jessica Marie Morales 12/25/1995 6<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5) This Is to certify that the information shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correclfor the person listed under Column (1) ofthe foregoing sheet(s) Is correclfor the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature<br />

Date Signature Date<br />

Title Agency<br />

Title School District<br />

This information is the basis for payment to this school district of federal fundS under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Properly: CA003069 Address: 7000 LACEY AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With PUpil'S Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Lois Thompkins 1424 50th Ave #2 X Kavon Newton 11/6/2001 1<br />

Lois Thompkins 1424 50th Ave #2 X Kevin Newton Jr 9/29/1997 5<br />

JACQUELINE TERRELUDANIE 5944 BROMLEY AVE #1 X Briana Parker 10/20/1992 9<br />

ALICIA MORTON/DON ROSS 1639 84th Ave #4 X Dalisa Ross 11/30/1995 6<br />

PAMELA DAVIS 7000 LACEY AVE #2 X Orshai Shaw 3/23/1993 9<br />

LAKEITHA STEWART 1730 85th Ave #1 X Sa'Vonta Slaughter 1214/1992 9<br />

STEPHANIE GREEN 3901 Webster St #6 X Rapheal Stewart 1/11/1994 8<br />

PAMELA DAVIS 7000 LACEY AVE #2 X Taz'Jay Tibbs 5/23/1999 3<br />

TAIVUTRAN 5944 BROMLEY AVE #4 X Annie Tran 7/24/1998 4<br />

TRANG LAM 5944 BROMLEY AVE #4 X Jennifer Tran 5/17/1994 8<br />

TAl TRAN (DAD) 5944 BROMLEY AVE #4 X TomTran 5/1/1995 6.<br />

DEBBIE RENEE WILSON 3901 WEBSTER ST #4 X Ida Wilson 12115/1990 11<br />

ROSELYN NORRISE 7000 Lacey Ave #6 X Darlen Wood 4/2211993 9<br />

Number Students At This Property 27<br />

ThIs Is to certIfy that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) is correcifor the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Title Agency<br />

Title School District<br />

This information Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003070 Address: 1324 E 32ND ST<br />

(1) (2) (3) (4) (5) (6) (7) (S)<br />

ParentlGuardian's ParentlGuardian's Branch of Service ParentlGuardian ParentlGuardlan Name of Pupil Living With, Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) ParentlGuardian in Date of Grade<br />

If applicable) lived on worked on Column (l) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

MARANDA JOHNSON 1324 E 32nd St #1 X Kamisha Abraham 7/7/1995 7<br />

GERALDINE MITCHELL 85 GARLAND AVE #2 X Jajaun Alcorn 9/12/1998 5<br />

DENISE JONES 85 GARLAND AVE #1 X Tyrius Ammons 8/14/1999 2<br />

RHONDA WILEY 9233 HILLSIDE ST #4 X Destiny Andrews 1/2/1999 3<br />

JERMAINE BARNETTE 3014 E 16TH ST #1 X JERMAINE BARNETTE JR 7113/2001 1<br />

KIM MORELAND/DELONDO BE 1324 E 32nd St #4 X Darius Bellamy 2/22/1991 10<br />

KIMBERLY ALDREDGE 1324 E 32ND ST #4 X Deja Bellamy 1/30/1996 6<br />

KIMBERLY ALDREDGEIDELON 1324 E 32ND ST #4 X Devon Bellamy 3/29/1993 9<br />

lisa Wiliams Robison 9233 Hillside St #2 X Salina Bishop 5/16/1993 9<br />

LADONNA BRIDGES/JERMAIN 3014 E 16TH ST #1 X Martin Bridges 1/8/1993 9<br />

EUGENE BROWN 1716 E 20TH ST #2 X Gena Brown 2/16/1994 8<br />

Maranda Johnson 1324 E 32nd St #1 X Taniya Coleman 9/10/2001<br />

Maranda johnson 1324 E 32nd St #1 X Tyquale Coleman 3/9/1999 2<br />

Melody & John Cooper 1486 77th Ave #2 X Shannon Cooper 6/14/2000 2<br />

This is to certify that the inlonnation shown under columns (4) and (5)<br />

01 the foregoing sheet(s) is correct lor the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

This is to certify that the <strong>In</strong>lonnation shown under columns (4) and (5)<br />

of the loregolng sheet(s) is correct lor the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Title Agency Tille School District<br />

This <strong>In</strong>lormation Is the basis lor payment to this school district 01 lederal lunds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003070 Address: 1324 E 32ND ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Luc Dang/Mai Tran 3010 E 16th St#4 X Dana Dang 11/21/2001<br />

TRAN MAI/LUC DANG 3010 E 16th ST #4 X Michael Dang 8/24/1999 3<br />

DENISE JONES 85 GARLAND AVE #1 X Calecia Detils 7/13/1991 10<br />

FRANCES EDWARDS 2226 94th Ave #2 X Donnell Dourtch 6/1/1993 8<br />

LASHAWN D. DUDLEY 1923 E 15TH ST #6 X Deneisha Dudley-Orr 5/211993 9<br />

ALEXIS BROOKS 866 37TH ST #3 X NAIYAH FLENOY 5/11/2001 1<br />

Frances A. Edwards 2226 94th Ave #2 X Ta'mya Harris 8/212002 0<br />

DANYNHEK 1919 E 15th St #2 X Darlene Hor 8/18/1992 10<br />

Dany NheklChhay Hor 1919 E 15th St#2 X Jessica Hor 4/10/2002 0<br />

DANY NHEKlCHHAY HOR 1919 E 15th St #2 X Larry Hor 1/14/1999 3<br />

Wanda Westiey 3366 62nd Ave #6 X William Jones 212712000 2<br />

WANDA WESLEY 3366 62ND AVE #6 X Willie Jones 11/4/1992 9<br />

Srey Khuth 1919 E 15th St #4 X Christina Khuth 8/26/1997 5<br />

Cheryl Lee 557 46th St #1 X Michelle Lee 8/611991 11<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5) This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1) of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature Date Signature Date<br />

Tltte Agency<br />

TItle School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Federal Property:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003070 Address: 1324E 32NDST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

ALEXIS S. BROOKS 866 37TH ST #3 X Monte Lee 11/1211994 8<br />

Cheryl Lee 557 46th ST #1 X Sabrina Lee 1/24/2002 0<br />

Chrystal RobertsiAvonte Lindsay 85 Garland Ave #2 X TeVian Lindsay 11/2812002 0<br />

CHARLENA DAVIS 2284 E 17TH ST#4 X Chardae McGown 6/16/1990 11<br />

CONSUELA LESTERIRanthony 716 34th St #4 X Ranthony Montgomery 9/27/1993 8<br />

LADDNNA BRIDGESIBARNETI 3014 E 16TH ST #1 X Chartiece Morris 11/6/1994 8<br />

LADECIA FITZPATRICK 1486 77TH AVE #1 X Tiffany Parker 4/3/1991 11<br />

TOUMKHAM PHOLSENA 1716 E 20TH ST #1 X Khemphet Pho/sena 1/11/1994 8<br />

Toumkham Pholsena 1716 E 20th St#1 X Souradet Pholsena 6/2211989 12<br />

April Lang(Susan Richard) 2226 94th Ave #3 X Dashawn Pierson 8/212000 1<br />

LEONA/RONALD E. PITIMAN 716 34TH ST #3 X Tannia Pittman 9/2211992 10<br />

LEONA PITIMAN/E MACK 716 34TH ST #3 X Tianna Pittman 3/2211990 12<br />

TANITA JOHNSON 1324 E 32nd St #1 X Britnee Price 9/4/1995 7<br />

Jimmey Parrish 2226 94th Ave #2 X Dawayne Robertson 10/24/1991 11<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet{s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (!il<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title School District<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


---------------------------


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003070 Address: 1324 E 32ND ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

CHHAY HORIDANY NKEK 1919E15thsl#2 X Sokhonthearal Seang 3/19/1994 8<br />

LASHAWN DUDLEY 1923 E 15TH ST #6 X JASHAWN SYKES 2123/2002 0<br />

LASHAWN D. DUDLEY 1923 E 15TH ST#6 X Jasmine Teny 216/1992 10<br />

MYEASHA STRAIN 557 46TH ST #3 X Robert Thompson 1/18/1993 8<br />

PARLEE THREETS 1716 E 20th Sl #3 X Tyesha Walker 9/21/1990 11<br />

Lisa WiJ/jams Robinson 9233 Hillside Sl #2 X Lalaina Williams 12116/1999 2<br />

DORIS HALL 9233 HILLSIDE ST #1 X James Woods 12111/1991 10<br />

Number Students At This Property 49<br />

This is to certify that the <strong>In</strong>fonnation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) is correctfor the person listed under Column (1)<br />

on the survey date.<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency<br />

Title School District<br />

This infonnation Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be sIgned and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003071 Address: 1621 HARRISON ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

LINDA SMITH 1621 Harrison St #703 X Dadisi Lee 7/3011993 7<br />

Yan Lin9 l-luanq 1621 Harrison SI#1310 X Qian You Li 7/8/2000 2<br />

PEI-TING ZHONG / Guo Shen9 1621 Harrison SI #506 X Amy Zhao 4/29/1993 9<br />

Number Students At This Property 3<br />

This is to certify that the information shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency<br />

Title School District<br />

ThiS information is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school distrIct to receive funds based on this <strong>In</strong>formation.


Federal Property:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003073 Address: 610 E 18TH ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

Christi Johnson/Anlwan Adger 610 E 18th St #J<br />

Kenya Williams 7636 Ney Ave #4<br />

YES I NO YES I NO<br />

X Antwanette Adger 10/5/2001 1<br />

X Rakya Banks 6/21/2002 0<br />

Helen Thomas 2468 Coolidge Ave #B X Diamond Baylor 217/1991 12<br />

LANITA WYATT 610 E 18TH ST #F<br />

ltika Robinson 1422 47th Ave #7<br />

MELODY FRYE/RICHARD ORA 7636 NEY AVE #3<br />

X Lanisha Branch 11/24/1994 8<br />

X Panaisla Brewer 1/25/2002 0<br />

X XAVIER DRAPER 4/29/2001 1<br />

KIM YOEUN EAP 3302 BROOKDALE AVE #2 X DonjaJica Eap 1213011992 9<br />

Donna Tompson 2468 Coolidge Ave #0<br />

KENYA WILLIAMS 7636 Ney Ave #4<br />

ANGELA LEE 755 ALCATRAZ AVE #H<br />

LAJOYA JUNIEL 755 ALCATRAZ AVE #1<br />

Ruan, Bing Bing/Hu. Wei Xiong 2925 E 16th St #3<br />

X Se'Quan Edmonds 6/2211995 7<br />

X Malik Grant Jr 11/29/1995 6<br />

X Jamie Harmon 2124/1991 10<br />

X QuenneJl Harris 1211/1990 12<br />

X Yong Hu 5/11/2002 0<br />

FLETCHER. JACKI E 610 E 18th St#E X Hassan Hunter 4/1/1997 5<br />

JACKIE FLETCHER 610 E 18th St#E<br />

This is to certify that the <strong>In</strong>fonnation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

X Malaysia Hunter 3/2511999 3<br />

This Is to certify that the <strong>In</strong>fonnatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Tille Agency Tille School District<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


---------------------


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003073 Address: 610 E 18TH ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

U'Lai Kenard 5653 Martin Luther King Jr Way X JaVon Kenard 9/10/2000 2<br />

Deborah Major-Minor 945 44th St #E X Daniel Major 11/19/1992 9<br />

GENAIL RANDELL & JIMMY MI 1422 47TH AVE #3 X Jamilla Mims 12/23/1993 7<br />

GENAIL RANDELL & JIMMY MI 1422 47TH AVE #3 X Shamilla Mims 1/29/1996 6<br />

Genall Randell 1422 47th Ave #3 X Jimmy Mims Jr 5/411997 5<br />

Nga Tran 2925 E 16th St #6 X Trinh Pham 11/3/1994 8<br />

Nga Tran 2925 E 16th St #6 X Van Pham 12/26/1998 3<br />

CYNTHIAfTONY PIPPiNS 2919 E 16th St#10 X Toni Pippins 8110/1996 6<br />

PECHSOT 2157 38th Ave X Semmara Sot 10/1/1991 10<br />

Donna Thompson 2468 Coolidge Ave #0 X Daveonte Thompson 9/12/1992 9<br />

NOE VEGAS TORRES 5661 MARTIN LUTHER KING J X Jennifer Vega-Vazquez 12/1/1996 5<br />

VOEUNIOUCH 610 E 18TH ST#H X Tierra Voeun 1/311996 6<br />

Jamilla Watts 2468 Coolidge Ave #C X Jakell Watts 2/1811998 4<br />

Jamilla Watts 2468 Coolidge Ave #C X Kevin Watts 812011995 6<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s} Is correctfor the person listed under Column (1)<br />

on the survey date.<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s} is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency<br />

Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Helen Thomas<br />

hong wei, liang<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003073 Address: 610 E 18TH ST<br />

(1) (2) (3) (4) (S) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

2468 Coolidge Ave #8<br />

610 E 18th St#K<br />

Number Students At This Property 30<br />

This is to certify that the information shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) is correct for the person listed under Coiumn (1)<br />

on the survey date.<br />

Signature<br />

YES I NO YES I NO<br />

x<br />

X<br />

Nicole Yarbough<br />

De HuaZou<br />

This is to certify that the information shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) is correclfor the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Tille Agency Title School District<br />

7/1711993<br />

11/27/1992<br />

This <strong>In</strong>formation is the basis for payment to this school district of federal funds under the Impact Aid Program (Tille VIII of the Elementary and Secondary E;ducation Act).<br />

ThIs form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.<br />

9<br />

9


------------------------------------------ -


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

FederalProperty: CA003074 Address: 3352ARKANSASST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

BENNYBACA 3350 ARKANSAS ST X Paul Baca 6/24/1991 10<br />

SHIRLEY BIRCHETT 1116E15THST X Shykelah Birchett 11/1/1994 8<br />

Barbara FreemanlRuben Crossg 3344 ARKANSAS ST #4 X Ruben Cross 7/19/1999 3<br />

Brian Grayson 1118 E 15th St X Ryant Grayson 2/6/1990 11<br />

Annstead, Myiesha 3346 Arkansas St X Daeshawn Johnson 11/9/2002 0<br />

Minnie Phifer 9232 Bancroft Ave #8 X Jeremy Paul 4/26/1990 12<br />

MYRTIS RANDLE 3344 ARKANSAS ST #3 X Kenneth Redertord 11/5/1997 4<br />

L1VIS(Pam) SANDERS 4825 WEBSTER ST #8 X Ro'Melio Sanders-Combs 8/27/1994 8<br />

RACHON WARRICK 3344 ARKANSAS ST #8 X Anthony Warrtck 2/4/1997 5<br />

ROCHON WARRICK 3344 ARKANSAS ST #8 X Joshua Warrick 1/19/1999 3<br />

TANISHA WHiTE 3346 ARKANSAS ST X Darrion White 3/28/1995 6<br />

Tanisha White 3346 ARKANSAS ST X Zhanaya White 12/4/1996 4<br />

TANISHA L. WHITE 3346 ARKANSAS ST X Daymeioun White-Hamilton 3/23/1999 3<br />

Sharon Wong/John Mitchell 3340 Arkansas St X Chrtstopher Jr Wong 10/30/2001 1<br />

This is to certify that the information shown under columns (4) and (6)<br />

olthe foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (6)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency<br />

Title School District<br />

ThIs information is the basis for payment to this school distrIct of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

Federal Property: CA003074 Address: 3352 ARKANSAS ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) in Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

Number Students At This Property 14<br />

This Is to certify that the <strong>In</strong>fonnation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

YES I NO YES I NO<br />

This Is to certify that the infonnation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency<br />

Title School District<br />

This infonnatlon Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003075 Address: 6130 HILTON ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

TINA L. ROBINSON 6126 HILTON ST #5 X Que Aire Anderson 7/28/1998 3<br />

SHERRY EVANS 4203 TERRACE ST #1 X Randolph Brooks Jr 9/26/1993 8<br />

Huong(Kelly) Nguyen 2000 E 21st St #3 X Han Nguyen Bui 6/18/2000 1<br />

HUONG NGUYEN 2000 E 21st 5t #3 X TimmyBui 6/211998 4<br />

Kimberly Carter Cleveland 3295 Lynde St #6 X Brenda Cooper 7/30/2002 0<br />

Jeanette Brown 3293 Lynde St #2 X James Frazier 11/16/1990 10<br />

TERRI CARTER 6126 HILTON ST #4 X Terilynn Gilmore 8/31/1993 9<br />

RilaWilllams 113163rd St#9 X Britney Harbin 6/14/1990 10<br />

DEBORAH BAILEY 1135 63RD ST #7 X Eronie Harris 6/26/1998 3<br />

CHARLES S. HOKES 59 PEARL ST #1 X Kevin Hokes III 1/9/1995 7<br />

CHARLES S. HOKES 1 Kimberly 59 PEARL ST #1 X Kevin Hokes Jr 8/14/1993 8<br />

CHRISTINE LE'BRANE 582 48th St #4 X Al-Tariq Jenkins 10/17/1993 8<br />

LaGashia Williams 4203 Terrace St #4 X Malik Keelas 5/5/2001 1<br />

CYNTHIA HOLLIS 6126 HILTON ST #3 X Malik Mapp 4/29/1998 4<br />

This Is to certify that the information shown under columns (4) and (5) This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1) ofthe foregoing sheet(s) Is correclfor the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature Date Signature Date<br />

Title Agency<br />

Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


FederalProperty:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

CA003075 Address: 6130 HILTONST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Atef Mohammed 3293 Lynde St #1 X Alia Mohammed 3/17/1993 9<br />

Judy Speech 59 Pearl St#6 X Daquata Moss 7/25/1990 11<br />

CONSTANCE MENEESE-NELS 59 Pearl St #7<br />

X Anthony Nelson 3/3011993 9<br />

Vickie L. Mohammed 3293 Lynde St #1 X Ghazi Naseir 11/19/1996 5<br />

Atef Mohammed 3293 Lynde St #1 X Layla Naseir 10/19/1998 3<br />

REGINA TURNER 6130 HILTON ST #8 X Charles Payne 11/2211990 11<br />

Harold Phillips 582 48th St #10 X Laron Phillips 9/1211992 9<br />

Chrtstine LeBrane 582 48th St #4 X Keoshi Pritchard 12128/1999 2<br />

Helen A. Johnson I Jerome Jam 3293 Lynde St #5 X Jalauni Range 1/27/1997 5<br />

Helen Johnson 3293 Lynde St #5<br />

X Jemauri Range 1/31/2001 1<br />

Richard. Roland & Crytal Drake 810 60th St #3 X Isaiah Albertino Richard 4/13/2001 1<br />

Crystal/Juanita Drake 810 60TH ST #3 X Jeremiah Richard 5/19/1999 3<br />

Barbie Hall/Latonya Hall 810 60th St #1 X Eboni Route 9114/1994 7<br />

Barbie Hall/Latonya Hall 810 60th St #1 X Essence Route 5/3/1993 9<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

Date Signature<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Title Agency Title School District<br />

This information Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.<br />

Date


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

Federal Property: CA003075 Address: 6130 HILTON ST<br />

Signature<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government surveydaie survey date<br />

YES I NO YES I NO<br />

Sandra Williams 3295 Lynde St #7 X Dejanay Ryan 1/1011998 3<br />

Latonia D. George 3291 Lynde St #8 X Dominique Samuels 7/17/1998 4<br />

DEANNA JOHNSON/ORLANDO 1135 63RD ST #6 X Alandra Smith 7/8/1992 9<br />

JACQUELINE/SAMUEL SMITH 4203 TERRACE ST #2 X Janina Smith 1/1911993 9<br />

FELICIA STEPHENS 582 48TH ST #1 X Lydell Smith 7/11/1997 4<br />

FELICIA STEPHENS 582 48TH ST #1 X Rhalani Smith 8/15/1998 4<br />

Melissa Tuggles 1130 62nd St#1 X Shaun Stanford 9/22/1999 2<br />

LAWANDA MARTIN 4203 TERRACE ST #1 X Dani Tarver 8/14/1998 4<br />

LAWANDA MARTIN 4203 TERRACE ST #1 X Danielle Tarver 9/1311996 6<br />

MARY DEMOLLE 6238 Seminary Ave #4 X Marquise Usher 12/13/1989 12<br />

Lagashia Williams 4203 Terrace St #4 X Kahleec Vauqhn 7/9/1998 4<br />

Nathaniel Ward 827 52nd St #3 X Brittney Ward 10/26/1994 7<br />

DEBRA WARD 113163RDST#11 X Kierra Ward 5/12/1992 10<br />

DONELLA HODGESjames 6238 SEMINARY AVE #3 X Damon Watkins 7/27/1994 7<br />

This is to certify that the information shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correclfor the person listed under Column (1)<br />

on the survey date.<br />

Date Signature<br />

This Is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Title Agancy Title School District<br />

This <strong>In</strong>formation is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this infonnation.<br />

Date


Federal Property:<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CA003075 Address: 6130 HILTON ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

ParenUGuardian's ParenUGuardian's Branch of Service ParenUGuardian ParenUGuardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) ParenUGuardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

DONELLA HODGES 6238 SEMINARY AVE #3 X Dominique Watkins 10/16/1991 9<br />

CAROLYN CARTER 6126 HILTON ST #4 X Porche Webb 11/811993 9<br />

CAROLYN CARTER 6126 Hilton St #4 X Kiana Wesley 4/211991 10<br />

RITA WILLIAMS 1131 63RD ST #9 X Brianna Williams 9/24/1993 9<br />

JUNAN LUSTER 59 PEARL ST #9 X Teaira Williams 1/30/1990 9<br />

Oneeca Williams 3295 Lynde St #7 X Yvette Williams II 10/13/1992 9<br />

LAURA PATRICK 2000 E 21st St #2 X Latifah Wilson 3/19/1992 10<br />

LAURA PATRICK 2000 E 21st ST #2 X Tashiya Wilson 7/19/1997 5<br />

LAURA PATRICK 2000 E 21st St #2 X T'Shun Wilson 9/1211990 10<br />

ANGELA WIMBERLY 582 48TH ST #2 X Anthony Wimberly 6/24/1989 12<br />

Number Students At This Property 52<br />

This Is to certify that the <strong>In</strong>fonnatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

This Is to certify that the <strong>In</strong>fonnation shown under columns (4) and (5)<br />

oflhe foregoing sheet(s) is correc!for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Title Agency Title School District<br />

This <strong>In</strong>fonnation Is the basis for payment to this school district offederal funds under the Impact Aid Program (Title VIII oflhe Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003076 Address: 1127 FOOTHILL BLVD<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

YVONNE BROWN 1127 FOOTHILL BLVD #303 X Myelsha Alexander 5/24/1991 11<br />

CHRISTY GOUDEAU 1127 FOOTHILL BLVD #103 X Rafael Amezquita 1/26/1997 5<br />

JUANA RODRIQUEZ 160811TH AVE #16 X Brenda Bautista 9/4/1992 10<br />

JUANA RODRIQUEZ 160811TH AVE #16 X Elisa Bautista 10/7/1995 6<br />

GWENDOLYN SMITH 1127 FOOTHILL BLVD #101 X Shalandus CaUp 1/1111995 7<br />

Tomico Anderson 1127 Foothill Blvd #203 X Kevin Davis 1111/1992 9<br />

Phalla Din 1606111hAve#14 X Paulina Din 12119/2001 0<br />

LUN ENG 160611TH AVE #14 X Ratlay Din 1/3011998 4<br />

LUMENG 1606 11TH AVE #14 X Vanaka Din 1/13/1994 8<br />

GWENDOLYN SMITH 1127 FOOTHILL BLVD #101 X Davian Dunwood 214/1999 2<br />

TONYA LANCASTER 1608111h ave #18 X Javaris Holmes 11/2211994 7<br />

TONYA LANCASTER 160811thAve#18 X Jayvier Holmes 21811997 5<br />

TONYA LANCASTER 1608 11th Ave #18 X Jordan Holmes 7/7/1998 4<br />

TONYA LANCASTER 1608111hAve#18 X Joshilyn Holmes 1/30/1996 6<br />

This Is to certify that the <strong>In</strong>fonnatlon shown under columns (4) and (5) This is to certify that the infonnation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) Is correct for the person listed under Column (1) of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature<br />

Date Signature Date<br />

Title Agency Title School District<br />

This <strong>In</strong>fonnation is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle Viii of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

FederalProperty: CA003076 Address: 1127 FOOTHILL BLVD<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, in Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Coiumn (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

TONYA LANCASTER 160811th ave #18 X Michael Holmes 1/7/1994 7<br />

ALISON BRODNAX 1610 11TH AVE #8 X Rodney Homage Jr 3/611991 10<br />

LE BE& RO NGUYEN 160811TH AVE #15 X Hon9 Le 5/4/1991 10<br />

BE LEiRO NGUYEN 160811TH AVE #15 X Peter Le 9/1011994 8<br />

Mary McLane 160611thAve#13 X Erica Miller 2124/1993 8<br />

DUNG NGUYEN 1127 FOOTHILL BLVD #204 X Donna Nguyen 9/211993 9<br />

tanya lancaster 160811thAve#18 X Jacarf Pearson 3/14/2001 1<br />

Tosha White 1127 Foothill Blvd #102 X Genal Reliford 2123/2001 1<br />

TOSHAWHITE 1127 Foothill Blvd #102 X George Reliford 3/29/1998 4<br />

Latonya Shivers 160811thAve#17 X Isaiah Rice 1/13/2002 0<br />

Roxchell Santee 1610 11th Ave #8 X Tyree Santee 9/27/1995 6<br />

Yvonne Brow 1127 Foothill Blvd #303 X Kevin Taylor 121212001 0<br />

BINH VU & THUY TRAN 1610 11TH AVE #4 X <strong>In</strong>finity T18n 4/1/1999 3<br />

Shante Dennis/Sheila Davis 160611thAve#11 X Dalaijah White 3/9/2001<br />

This Is to certify that the <strong>In</strong>lonmatlon shown under columns (4) and (5) This is to certify that the <strong>In</strong>fonmatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1) of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title<br />

School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (TItle VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

TRAVIS TANKA<br />

TANIKA TRAVIS<br />

TANIKA TRAVIS<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003076 Address: 1127 FOOTHILL BLVD<br />

160811TH AVE #20<br />

160811TH AVE #20<br />

160811TH AVE #20<br />

Number Students At This Property 31<br />

This is to certify that the infonnatlon shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

YES I NO YES I NO<br />

x<br />

X<br />

X<br />

Kalyce Woods<br />

Kyjhae Woods<br />

Kyjhanaa Woods<br />

This Is to certify that the infonnation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title<br />

School District<br />

1/11/1994<br />

8/22/1995<br />

8/22/1995<br />

This <strong>In</strong>fonnatlon Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.<br />

8<br />

7<br />

7


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

Federal Property: CA003077 Address: 4100 ALLENDALE AVE<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, in Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

TAMERA DANIELS 4100 Allendale Ave #2 X T'ReliAdams 11/4/1995 7<br />

Bernadine Russ/Dwayne butler 4068 ALLENDALE AVE #5 X Aryannah Butler 6/27/1991 11<br />

BERNADINE BUTLER 4068 ALLENDALE AVE #5 X Dwayne Butler 6/23/1998 4<br />

KENYA SMITH-EDWARDS 1458 52ND AVE #1 X Kemari Edwards 11/28/1996 6<br />

KERAMOZON 10221 STANLEY AVE #3 X Tayuan Lubin 3/9/2002 0<br />

georgina vazzie 3590 Lincoln Ave #4 X maricela martin 6/25/2001 1<br />

LINDA SANDIFER 3590 LINCOLN AVE #3 X Aaron Oakes 8/2211990 11<br />

ANGELA JAMES 2439 E 21ST ST #1 X Mikianna Thompson 6/25/1996 5<br />

BRIANNA MORTON 3590 LINCOLN AVE #2 X Lawrence Vickers 12131/1992 8<br />

GERALDINE CAMPBELL 2439 E 21st St #1 X Damon Williams 11/10/1992 9<br />

Number Students At This Property 10<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

oflhe foregoing sheet(s) is correctforthe person listed under Column (1)<br />

on the survey date.<br />

This is to certify that the information shown under columns (4) and (5)<br />

oflhe foregoing sheet(s) is correctfor the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature<br />

Date<br />

Title Agency Tille<br />

School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title Viii of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

Federal Properly: CAO03078 Address: 537 32ND ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

ParentlGuardian's ParentlGuardian's Branch of Service ParentlGuardlan ParentlGuardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) ParentlGuardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Govemment survey date survey date<br />

YES I NO YES I NO<br />

KATRINA HOLLY/ALAN AUSTI 541 32ND ST #1 X Aaron Austin 1/1811991 9<br />

Katrina Holly 541 32nd SI #1 X Alan Austin 211211993 9<br />

KATRINA HOLLY ALAN AUSTI 541 32ND ST #1 X Arneal Austin 3/18/1999 3<br />

SHERRY BOLES 1905 SEMINARY AVE #4 X Yasmine Boles 8/18/1998 4<br />

MARIA CABRERA/Luis Zamora 1905 SEMINARY AVE #3 X Adrian Cabrera 8/3/1999 3<br />

Maria Cabrera 1905 Seminary Ave #3 X Arturo Cabrera 1/26/2001 1<br />

ANGELINA CURIEL 541 32ND ST #4 X Glijah Curiel-Roberson 12113/2000 1<br />

DEATRESE BONNERIZEDDIE 717 43rd SI#3 X Edward Davis 4/19/1992 10<br />

SUE ANDERSON (GUAR) 537 32ND ST #2 X Devanae Harris 1/15/1991 11<br />

SUE ANDERSON 537 32ND ST #2 X Eyama Harris 4/10/1993 9<br />

KAI HUNG LEE 1915 SEMINARY AVE #17 X Myra Lee 7/2811991 11<br />

Corinne Blacknell 537 32nd SI #3 X Omari McElvaine 2127/2001 1<br />

Consuelo Ramirez 1915 Seminary Ave #18 X Armando Monroy 5/31/2000 1<br />

Consuelo Ramirez 1915 Seminary Ave #18 X Gloria Monroy 5/7/2002 0<br />

This is to certify that the information shown under columns (4) and (5) This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1) ofthe foregoing sheet(s) is correclfor the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature<br />

Date Signature Date<br />

Titie Agency<br />

Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title Viii of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003078 Address: 537 32ND ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

JOYCE PIERCE 717 43RD ST #2 X Kyle Pierce-Hamilton 9/2211990 11<br />

Juanita Maria Thomas 1905 Seminary Ave #2 X Paul Pills 3/14/2001 1<br />

SHALIMAR MOORE 541 32nd St #6 X Kenyada Whitten 9/24/1995 6<br />

Tanisha Perryman 1915 Seminary Ave #13 X Dejontae Wilson 9/29/2001 0<br />

Tanisha Perryman 1915 Seminary Ave #13 X Elonjanae Wilson-Banks 8/25/2002 0<br />

Number Students At This Property 19<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

ofthe foregoing sheet(s) is correclfor the person listed under Coiumn (1)<br />

on the survey date.<br />

This is to certify that the information shown under coiumns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title<br />

Agency Titie School District<br />

This information is the basis for payment to this school district of federai funds under the impact Aid Program (Title VIIi of the Eiementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Federal Property:<br />

Tia Triplett<br />

(1)<br />

Parent/Guardian's<br />

Name<br />

Viola Hampton/Audrey Dirden<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

CAO03080 Address:<br />

(2) (3)<br />

(4)<br />

Parent/Guardian's<br />

Address<br />

570 16th St #405<br />

570 16th St #218<br />

Branch of Service<br />

(<strong>In</strong>cluding rank,<br />

If applicable)<br />

or<br />

Foreign Military<br />

Government<br />

Number Students At This Property 2<br />

This Is to certify that the <strong>In</strong>fonmatlon shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correctfor the person listed under Column (1)<br />

on the survey date.<br />

Parent/Guardian<br />

<strong>In</strong> Column (1)<br />

lived on<br />

above property<br />

as of<br />

survey date<br />

YES I NO<br />

x<br />

X<br />

OAK GROVE SOUTH<br />

(5) (6)<br />

Parent/Guardian<br />

<strong>In</strong> Column (1)<br />

worked on<br />

above property<br />

as of<br />

survey date<br />

YES I NO<br />

Name of Pupil Living With<br />

Parent/Guardian <strong>In</strong><br />

Column (1)<br />

Jazzmine Jones<br />

Zaire Smith<br />

This Is to certify that the infonmatlon shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title<br />

School District<br />

(7)<br />

Pupil's<br />

Date of<br />

Birth<br />

11/19/1995<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.<br />

7/212001<br />

(8)<br />

PUpil's<br />

Grade<br />

6


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003081 Address: 2323 LINDEN 5T<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

Saba Tesfay 2229 Linden ST X Mekelawit Atakilti 4/3011993 9<br />

ORA BOHANNON 2230 Chestnut St X Orvon Bowen 9/9/1998 4<br />

Tasha Victoria Tugman 2236 Chestnut St X Natasha Dam 7/212001 1<br />

Diane Lee 2238 CHESTNUT ST X Michael Gillis 1/2511998 4<br />

Diane Lee 2238 Chestnut St X Rayn Gillis 8/13/1996 6<br />

Bobby Hamilton 2238 Chestnut St X Avalon Hamilton 2121/1997 5<br />

TASHA TUGMAN 2236 CHESTNUT ST X Danielle Hokes 9/611993 8<br />

TASHA TUGMMAN 2236 CHESTNUT ST X David Hokes Jr 9/6/1993 8<br />

Ureka Rose 2248 CHESTNUT ST X Shawn Holmes 8/14/1994 8<br />

Shi~ey Lee 2238 CHESTNUT ST X Donald Howard Jr. 10/2211997 5<br />

Joleah C Jackson/Seedric L Jac 2319 Linden St X Scedric Jackson Jr 1/25/2002 0<br />

Surenily Johnson/Jenny McDanl 2313 Linden St X Shyianna Johnson 6/7/1998 4<br />

Saba Tesfay 2229 Linden St X Samuel Kassa 4/811997 5<br />

LAURENE KILLIP 2305 LINDEN ST X lesha Killip 10/5/1991 10<br />

This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheel(s) is correct for the person listed under Column (1)<br />

on the surVey date.<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature<br />

Date<br />

Title Agency Title School District<br />

This information is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school distrIct to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003081 Address: 2323 LINDEN ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

LADONNA DROMGOOLE 2311 LINDEN ST X Bra King 9/29/2002 0<br />

MONICA WILSON 2237 LINDEN ST X Jamon Morton 7/18/1991 10<br />

EDNA MCCULLOUGH/Ureka Ro 2248 CHESTNUT ST X Gerureka Price 10/2811995 7<br />

ANTOINEITE SANDERS 2318 CHESTNUT ST X DEVIAN PRYOR 218/2001 1<br />

TASHA TUGMAN 2236 CHESTNUT ST X Tommy Ramsey III 11/211991 9<br />

GALENIA GOINS 2237 LINDEN ST X Dessiness Robinson 7/20/1993 9<br />

SOPHENMEY 2239 LINDEN ST X Alena Raeun 5/4/1994 8<br />

EDNA MCCULLOUGH 2248 CHESTNUT ST X Umiika Rose 2120/1997 5<br />

NAKISHA WILLIAMS 2227 LINDEN ST X Michael Roy Jr 10/20/2001 1<br />

ORA BOHANNON 2230 Chestnut St X Marcus Ruben 9/5/1994 7<br />

savann San 2320 Chestnut St X Chansophanin San 10/19/1992 10<br />

Savann San 2320 Chestnut St X Phoummara SAN 3/25/1996 6<br />

Demina Shannon 2249 Linden St X Jordan Shannon 4/23/2001 1<br />

Banho Som/Soknou Sen9 2308 Chestnut St X Pugna Som 8/13/2002 0<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

olthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this school district offederal funds under the Impact Aid Program (Title VIII olthe Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003081 Address: 2323 LINDENST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

SOUKCHANH SOURYASAK 2239 Linden SI X Cathleen Souryasak 4nJ1990 12<br />

DENISE TUGMAN 2236 CHESTNUT ST X Johnathan Tugman 1/28/1994 8<br />

Tasha Tugman 2236 Chestnut St X Michael Tugman 3/26/1996 6<br />

FENGX. YU 2241 Linden SI X Amy Wen 8/19/1996 6<br />

OIUJIAWEN 2241 LINDEN ST X Xing Hua Wen 6/18/1991 11<br />

Ureka Rose/Edna McCullough 2248 Chestnut St X Torrianna Wilson 8/10/2001 1<br />

Ladonna Dromquole 2311 LINDEN ST X Roy Woodrow 6/29/1997 5<br />

Number Students At This Property 35<br />

This Is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature Date Signature Date<br />

Title Agency<br />

Tille School District<br />

This information Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


.. "... ,---


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003082 Address: 1089 26TH ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

CHEMERRY BAZILE 1089 26TH ST #113 X Shamire Bazile 1/7/1998 4<br />

SONJI D FORT 1089 26TH ST #136 X Jasmine Beverly 12124/1989 12<br />

SONJI FORT 1089 26th St #136 X Shonise Beverly 11/26/1991 11<br />

Chemerry Bazile 1089 26th St #113 X Tierra Blake 4/17/2000 2<br />

Solomon Feleke/Debra Feleke 1089 26th St #132 X Mekyle Feleke 1/1012002 0<br />

Debra Feleke 1089 26th St #132 X Melaak Feleke 5/211999 3<br />

Vickie Liu 1089 26th ST #213 X Willie Feng-Liu 11/14/2001 1<br />

Sonja Port 1089 26th ST #136 X Sontaceec Garza 8/212002 0<br />

GRUBBS, VANESSA 1089 26TH ST #126 X James Grubbs 4/811990 12<br />

Vanessa Grubbs / James Ferrell 1089 26th St #126 X Jacob Hall 12119/1993 7<br />

Annemarie Johnson 1089 26TH ST #128 X Ashley Johnson 9/26/1996 6<br />

ANNA MARIE JOHNSON/Arthur 1089 26TH ST #128 X LaDonna Johnson 7/30/1992 9<br />

Qasim KhalaqilJawhara Ahmed 1089 26th St #127 X Ali Khalaqi 11/3/1995 5<br />

Qasim KhalaqilJawhara Ahmed 1089 26th SI #127 X Arsalan Khalaqi 3/17/1998 4<br />

This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />

on the survey date.<br />

Signature<br />

This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date.<br />

Date Signature Date<br />

Title Agency Title School District<br />

This <strong>In</strong>formation Is the basis for payment to this SChOOldistrict of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.


Impact Aid Program Source Check Form Extract<br />

The survey date is December 11, 2007.<br />

Federal Property: CA003082 Address: 1089 26TH ST<br />

(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With. Pupil's Pupil's<br />

Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

If applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

YES I NO YES I NO<br />

KHOUNKHUM 1089 26th ST #129 X Peter Khoun 71711990 12<br />

Qasim Khulaqi 1089 261hSI #127 X Salah Khulaqi 7/9/1991 10<br />

Qasem Rashed 1089 26th St #127 X Tehap khulaqi 8/5/1994 8<br />

Daneceia Bender 1089 26th SI #102 X Elias Lang 3/212001 1<br />

Danecei Bender 1089 261hSI #102 X Eneceia Lang 1/212000 2<br />

SHATIRESHA FULLMORE 1089 26TH ST #210 X Raymond Lee 4/13/1999 3<br />

FILIBERTO MALDONADO 1089 26TH ST #120 X Alejandro Maldonado 7/29/1997 4<br />

ANDRES MALDONADO/MARTI 1089 26TH ST #131 X Andres Maldonado 10/19/1990 12<br />

MARTINA MALDONADO 1089 26TH ST #131 X Jesus Maldonado 11/14/1991 10<br />

Andres/Martina Maldonado 1089 26th St #131 X John Maldonado 6/20/2001 1<br />

Maldonado, Filiberto & Reyna 1089 26th SI #120 X Juritzy Maldonado 7/8/2002 0<br />

VANESSA GRUBBS 1089 26TH ST #126 X Jimica Mcholder 12113/1992 8<br />

AnnMarie Johnson 1089 26TH ST #128 X Charlene Moyd 1/14/1996 6<br />

Aniya Sharee Henry 1089 26th SI #310 X De'Ojanae Phillips 1213/2000 1<br />

This is to certify that the infonnation shown under columns (4) and (5) This is to certify that the infonnalion shown under columns (4) and (5)<br />

olthe foregoing sheet(s) is correct for the person listed under Column (1) of the foregoing sheet(s) is correct for the person listed under Column (1)<br />

on the survey date. on the survey date.<br />

Signature Date Signature Date<br />

Title Agency TItle School District<br />

This <strong>In</strong>fonnatlon Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this information.


(1) (2) (3) (4) (5) (6) (7) (8)<br />

Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's<br />

Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />

if applicable) lived on worked on Column (1) Birth<br />

or above property above property<br />

Foreign Military as of as of<br />

Government survey date survey date<br />

Chemerry Bazile<br />

VANESSA GRUBB<br />

Hoa Tran/Kimyen Nguyen<br />

Impact Aid Program Source Check Form Extract<br />

The survey date is December 11,2007.<br />

Federal Property: CA003082 Address: 1089 26TH 8T<br />

1089 26th St#113<br />

1089 26TH ST#126<br />

1089 26th St#321<br />

Number Students At This Property = 31<br />

Total Number Students = 1,382<br />

YES I NO YES I NO<br />

x<br />

X<br />

X<br />

Mantell Cornell Smith<br />

Joseph Thomas<br />

Quochuy Tran<br />

This is to certify that the information shown under columns (4) and (5)<br />

of the foregoing sheet(s) Is corr ct f th person listed under Column (1)<br />

on the survey dat<br />

Chief Financial Officer<br />

Title<br />

e<br />

1/28/08<br />

1/2/2002<br />

11120/1991<br />

2120/1990<br />

Oakland Unified School District<br />

School District<br />

This information Is the basis for payment to this school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act).<br />

This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>fonnation.<br />

o<br />

9<br />

10

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