File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
FederalProperty: CA003023 Address: 675 30TH #
(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 Coiumn (1) In Coiumn (1) Parent/Guardian in Date of Grade
if applicabie)
or
lived on
above property
worked on
above property
Coiumn (1) Birth
r
Foreign Military as of as of
Government survey date survey date
YES I NO YES I NO
CAROL CHRISTOPHER 675 30TH ST #5 X Jazz Christopher 1/31/1995 7
CAROL CHRISTOPHER 675 30TH ST #5 X Lashayla Christopher 5/24/1993 8
TASHA LANDRY 675 30th St #3 X Jayvon Landry 8/12/1995 7
Monlque Green/Sirclinton Nelso 675 30th St #1 X Dejah Nelson 712112001 1
Anthony Pierce 675 30th St #2 X Lavonte Pierce 4/14/1992 9
Number Students At This Property 5
This is to certify that the information shown under columns (4) and (5)
olthe foregoing sheet(s) is correctfor the person listed under Column (1)
on the survey date.
This is to certify that the information shown under columns (4) and (5)
of the foregoing 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 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).
This form must be signed and dated for this school district to receive funds based on this information.