File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
Federal Property: CA003033 Address: 5009 CONGRESS 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
PAMELA BROWN 5009 Congress Ave #1 x Avante' Arrington 2/11/1992 9
Number Students At This Property 1
This Is to certify that the information shown under columns (4) and (5)
ofihe 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)
ofihe foregoing sheet(s) Is correcltor the person listed under Column (1)
on the survey date.
Signature Date Signature Date
Tille Agency Till. 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.