File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11,2007.
Federal Property: CAO03020 Address: 2272 E 19TH ST
(1) (2) (3) (4) (5) (6) (7) (8)
Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's
Name Address (including rank, In Column (1) In Column (1) Parent/Guardian in Date of Grade
if applicable) lived on worked on Column (1) Birth
or above property above property
Foreign Military as of as of
Government survey date survey date
YES I NO YES I NO
Maria Lott 2272 E 19th St #1 X Michaela Allums 9/21/1999 3
ALICIA GRAYSON 1750 E 21ST ST #4 X Shaneeka Harris 5nJ1994 7
RASHIMA BELLAMY 1750 E 21ST ST #1 X Jzanik Hicks 8/15/1992 10
ALICE GRAYSON/ALICIA GRA 1750 E 21ST ST #4 X Marcellous Lewis 12119/1990 9
Dynese Horace 1750E21stSt#5 X A10nLynn-Hurth 10/15/1996 5
DEVONEE BELLAMY 1750 E 21ST ST #1 X Fronchonte Stewart 3/2211994 8
LUANTRUONG 2272 E 19th St #2 X Tho Tran 10/13/1991 10
THACH TRANITRUONG LUAN 2272 E 19th St #2 X Truong Tran 2124/1990 12
MARIALOTT 2272 E 19TH ST #1 X Kamillah Webb 8/31/1994 7
Number Students At This Property 9
This is to certify that the Infonmation shown under columns (4) and (5)
of the foregoing sheet(s) is correct for the person listed under Column (1)
on the survey date.
This is to certify that thelnfonmation shown under columns (4) and (5)
of the loregoing sheet(s) Is correct for the person listed under Column (1)
on the survey date.
Signature Date Signature Date
Title Agency Title School District
This Inlonmation 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).
This form must be signed and dated for this school district to receive funds based on this information.