File In No. tJ ~- 6 Obb

Federal Property:
Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
CA003026 Address: 2416 88TH AVE
(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 T NO YES I NO
Samban Hem 2416 88TH AVE #3 X Xavier Joseph 8/6/1997 5
IKIMIA L. KING 76841ST ST#1 X lakiriyya Karimusha 6/27/1995 7
KIM MURPHY 768 41ST ST #2 X Kelton Runnels 2110/1997 5
KIM MURPHY 76841STST#2 X Khalanl Runnels 5/19/1999 3
MYRNA MCDANIEL 76841STST#6 X Emari Walker 10/16/1998 3
MYRNA MC DANIEL 76841ST ST#6 X Edmond Walker IV 91711996 5
TOUCHYONG 768 41ST ST #3 X Johnny Yonq 11/3/1996 5
TOUCHYONG 76841STST#3 X KellyYon9 1219/1990 10
Number Students At This Property 8
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.
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 Coiumn (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 Eiementary and Secondary Education Act).
this form must be signed and dated for this school district to receive funds based on this information.