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Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
Federal Property: CA003035 Address: 6916 ARTHUR 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 (including 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 Military as of as of<br />
Government survey date survey date<br />
YES I NO YES I NO<br />
Terrel & Kaya Sidney 6916 Arthur St #A X Terreli Beker 5/14/1997 4<br />
Myisha Myrick 2626 E21stSt#C X Auntrice Brooks 9/3/2001<br />
MYISHA MYRICK 2626 E 21ST ST #C X Jayla Brooks 1/17/1996 6<br />
CHATISSE MATHEWS 1521 92ND AVE #B X Earnest Henderson 11/25/1996 6<br />
CHATRISSE MATHEWS 1521 92ND AVE #B X Tierra Henderson 3/19/1994 6<br />
Ynagnaca Dixon 2626 E 21st St #A X Hemaciona Henry 4/19/1992 10<br />
Juliette Hutchinson 2626E21stSt#D X Nakiyah Hutchinson 2/21/1990 12<br />
WYNONA PRICE 9711 SUNNYSIDE ST #B X Christilyn Mcneal 8/18/1991 10<br />
ANNICE EVANS 9711 SUNNYSIDE ST #E X Angel Ramos 6/3/1995 7<br />
ANNICE EVANS 9711 SUNNYSIDE ST #E X Dante Ramos 10/16/1996 6<br />
NATASHA JENKINS 6916 ARTHUR ST #B X Tah'Ree Razo 6/8/1997 5<br />
Labrina McClainlEmsto Rosales 1521 92nd Ave #E X Luzelena Rosales 1/19/1998 4<br />
ANNICE EVANS 9711 SUNNYSIDE ST #E X Antionetle Saddler 8/24/1993 9<br />
Number Students At This Property 13<br />
This is to certify that the infonnatlon shown under columns (4) and (5)<br />
olthe foregoing sheet(s) Is correctfor the person listed under Column (1)<br />
on the survey date.<br />
Signature<br />
Title<br />
This is to certify that the infonnatlon shown under columns (4) and (5)<br />
of the foregoing sheet(s) is correct for the person listed under Column (1)<br />
on the survey date.<br />
Date Signature Date<br />
Agency Title School District<br />
This infonnation is the basis for payment to this school district of federal funds under the Impact Aid Program (TIlle 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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