File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
FederalProperty: CA003039 Address: 2315 98TH 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
GERALDINE WILLIAMS 2317 98TH AVE #3 X Ebony Donnley 5/2211990 12
Tabasamu Barksdale 2317 98th Ave #2 X Dayshia Gaines 9/16/1996 5
Tabasamu BarksdalelRay Gain. 2317 98th Ave #2 X Destiny Gaines 7/11/2000 1
Carter, Michelle Renee 2317 98th Ave #1 X Makayla Surrell 5/28/1998 3
Michelle Renee carter 2317 98th Ave #1 X Makeal Surrell 8/1/1999 3
Carter, Michelle Renee 2317 98th Ave #1 X Makiya Surrell 11115/2000 2
Number Students At This Property 6
This Is to certify that the information shown under columns (4) and (5)
ofthe foregoing sheet(s) Is correclfor the person listed under Column (1)
on the survey date.
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.
Signature Date Signature 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.