File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
FederalProperty: CA003028 Address: 7209 HOllY ST
(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 I NO YES I NO
Theresa Batts 7209 Holly St #1 X Anthony Batts 10/18/2001 1
THERESA BATTS 7209 HOLLY ST #1 X Ladarius Batts 6/21/1991 11
THERESA BATTS 7209 HOLLY ST #1 X Destiny Gray 6/18/1999 3
THERESA BATTS 7209 HOLLY ST #1 X O'Onshana Holmes 2/16/1994 8
ERSULA CAPERS 7209 HOLLY ST #2 X Brittney Jones 4/30/1990 11
Batts TheresaJErsula Capers 7209 Holly St #2 X Eric Radford 4/16/1992 9
Number Students At This Property 6
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)
ofthe 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.