File In No. tJ ~- 6 Obb

Signature
Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
FederalProperty: CA003030 Address: 1739 89TH 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 I NO YES I NO
EVORA JACKSONIMARLON F 1739 89th Ave #5 X Shamara Fountain 10/25/1990 11
YOLONDA SCOGGINS 1739 89th Ave #4 X Dante Gohleston 12118/1990 11
Kathleen Hewitt 4005 LYON AVE #5 X Devonte Hewitt 7/1/1991 9
IIESHA K. MOOREIStephanie W 1739 89TH AVE #2 X Elisha Johnson 9/1411994 7
VENUS POLK-SPENCER 4005 Lyon Ave #5 X Vanessa Spencer 1218/1990 11
Martell WashingtonlCorey Picke 4005 Lyon Ave #5 X Marshay Washington-Estes 1/11/2002 0
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.
Date Signature
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.
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.
Date