File In No. tJ ~- 6 Obb

(1) (2) (3) (4) (5) (6) (7) (8)
ParentlGuardian's ParentlGuardian's Branch of Service ParentlGuardian ParentlGuardian Name of Pupil Living With Pupil's Pupil's
Name Address (including rank, In Column (1) In Column (1) ParentlGuardian 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
ALYSIA LUCAS
SAECHAO MANH
SHIDAH SHABAZZ
Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
FederalProperty: CA003036 Address: 2146 E 24TH ST #
2146 E 24TH ST #B
2146 E 24th ST #A
2146 E 24th SI #C
Number Students At This Property 3
This Is to certify that the Infonnatlon shown under columns (4) and (5)
of the foregoing sheet(s)is correct for the person listed under Column (1)
on the survey date.
YES I NO YES I NO
x
X
X
LakiraMcClain
Brian Saechao
MalikahShabazzBowie
This Is to certify that the Infonnation shown under columns (4) and (5)
olthe 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
9/3/2002
12/19/1993
This Infonnation Is the basis for paymentto this school district of federalfunds under the Impact Aid Program(TItleViii of the Elementaryand SecondaryEducation Act).
This form must be signed and dated for this school district to receive funds based on this information.
2/5/1991
o
8
11