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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
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