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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. '
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