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Impact Aid Program Source Check Form Extract<br />
The survey date is December 11,2007.<br />
Federal Property: 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 (<strong>In</strong>cluding 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 Mliltary as of as of<br />
Government survey date survey date<br />
YES I NO YES I NO<br />
KATRINA PERRY 9500 SUNNYSIDE ST #8 X Rickeya Smith 4/26/1995 7<br />
Tamla Lipscomb 7908 NEY AVE #1 X Michaela Stamps 7/29/1998 4<br />
BRENDA MARTIN 7908 NEY AVE #1 X Dale Starks Jr 3/18/1993 8<br />
NIKI EVANS 9510 SUNNYSIDE ST #7 X TATIANNA STEWART 3/1212002 0<br />
SHIEDA RIDLEY 7908 Ney Ave #5 X Andrew Thomas 9/6/1992 9<br />
Samun KeamlRonth Kearn 2023 24th Ave #1 X Sokchanthra Uch 2114/2000 2<br />
Ronth Kearn 2023 24th Ave #1 X Cita Va 10/18/2002 0<br />
LEVETTE M. BUFFIN 9500 SUNNYSIDE ST #5 X Arrianna Varello 4/27/1999 3<br />
LATASHA THOMAS 2032 E 26th St #5 X Dejan Vasquez 5/211994 8<br />
LATASHA THOMAS 2032 E 26TH ST #5 X Tashawna Vasquez 1211311990 11<br />
TARNISHA WASHINGTON 1815 28th Ave #4 X Tayjah Washington 1/1211995 7<br />
HANNIBAL WILLIS 1815 28th Ave #10 X Brianna Willis 5/13/1993 8<br />
ERICKA WILLIAMS/Hannibal Wi 1815 28TH AVE #10 X Hannibal Willis Jr 4/28/1996 6<br />
Owens Nicole 9510 Sunnyside St #3 X Markell Wooley 1/1/2000 2<br />
This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5) 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) ofthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />
on the survey date. on the survey date.<br />
Signature Date Signature<br />
Date<br />
Title Agency Title 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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