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Federal Property:<br />
Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
CA003040 Address: 2402 E 27TH ST<br />
Signature<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 (<strong>In</strong>cluding 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 />
DARLENE DAVISfTALCE EVAN 2402 E 27TH ST #7 X Talce Evans 1/13/1993 9<br />
Myeesha Harris 2402 E 27th St #5 X Tyrese Franklin 8/27/2000 2<br />
Desiree Bradford 2402 E 27th St #4 X Isaiah Jackson 9/25/2002 0<br />
Desiree R. Bradford 2402 E 27TH ST #4 X Lavell Jackson 11/3/1995 6<br />
Desiree Bradford 2402 E 27th St #4 X 8t James Jackson 7/16/1997 5<br />
KRiSTY HEI LUM WANG 2402 E 27TH ST #3 X Ashley Li 1/15/1999 3<br />
KRISTY H. WANG 2402 E 27TH ST #3 X Cody Li 3/21/1996 6<br />
KRISTY HEI LUM WANG 2402 E 27TH ST #3 X Emily LI 1/15/1999 3<br />
KRISTY H. WANG 2402 E 27TH ST #3 X Erica Li 2/25/1997 5<br />
TERESA DOUGLAS 2402 E 27th St #8 X Tyree McCoy 4/11/2001 1<br />
CHANNAMEY 2402 E 27TH ST #2 X Amanda Mey 5/14/1991 11<br />
SHEREE R. HOLLINS 2402 E 27TH ST #1 X Raeshonna Smith 1/2011995 5<br />
SHEREE HOLLINS 2402 E 27TH ST #1 X Roland Smith Jr 2/1/1995 7<br />
MYEESHA HARRIS 2402 E 27TH ST #5 X Tahjanay Ward 12/2/1995 7<br />
This Is to certify that the information shown under columns (4) and (5)<br />
olthe foregoing sheet{s) Is correct for the person listed under Column (1)<br />
This Is to certify that the information 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 />
on the survey date.<br />
Title<br />
Date<br />
Agency<br />
Signature<br />
Title<br />
Date<br />
School District<br />
This <strong>In</strong>formation 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).<br />
This form must be signed and dated for this school district to receive funds based on this information.
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