File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
FederalProperty: CA003040 Address: 2402 E 27TH ST
(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
Number Students At This Property 14
This is to certify that the information shown under columns (4) and (5)
olthe foregoing sheet(s) is correctfor the person listed under Column (1)
on the survey date.
Signature
Title
YES I NO YES I NO
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.
Date Signature Date
Agency Title School District
This Information 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).
This form must be signed and dated for this school district to receive funds based on this Information.