File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
FederalProperty: CA003032 Address: 4908 CONGRESS AVE
(1) (2) (3) (4) (5) (5) (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
Govemment survey date survey date
YES I NO YES I NO
Aaesha Holloway/Jermaine Brya 4908 Congress Ave #2 X Jermanl Bryant 12110/2000
MILEHANNAH PERRY 4908 Congress Ave #3 X MARIO GANT JR 5/29/2002 0
Latanya Robinson 4908 Congress Ave #1 X Tkeyah Poco 3/2211991 10
WILLIE SCOTT 1599 54TH AVE #3 X Willie Scott 4110/1995 7
TINISHA GRAY 1599 54TH AVE #3 X Taylor Simmons 12117/1994 7
Latanya Robinson 4908 Congress Ave #1 X Tamia Swann 1/25/1995 6
Number StUdents At This Property 6
This is to certify that the infonmatlon shown under columns (4) and (5)
ofthe foregoing sheet(s) is correct for the person listed under Column (1)
on the sUlVey date.
This is to certify that the infonmatlon shown under columns (4) and (5)
of the foregoing sheet(s) is correct for the person listed under Column (1)
on the sUlVey date.
Signature Date Signature
Date
Titie Agency Title
School District
This Infonmation is the basis for paymentto this school district of federal funds under the Impact Aid Program (TItle VIII ofthe Elementary and Secondary Education Act).
This form must be signed and dated for this school district to receive funds based on this information.