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Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
FederalProperty: CA003047 Address: 56529TH 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 />
Wanda Stallings 630 Apgar St #4 X Roshawn Crenshaw 9/17/1990 10<br />
Oanesha Lindsey 725 39th St #3 X Keymari Davis 4/18/1997 3<br />
KATHERINE BRADFORD/ELY 7950 Ney Ave #2 X Keirra Ely 5/17/1995 7<br />
MARIA ESCUDERO 5625 CANNING ST #12 X Dominique Escudero 10/611989 11<br />
Khrystal Gomes/Macarie Ford 565 29th St #4 X Spencer Graham 8/30/1998 4<br />
Daneshia Powell 933 46th St #5 X Deja Gresham 6/9/1997 5<br />
MONIQUE GUITON 5625 CANNING ST #9 X Connectis Guiton Jr 2/12/1991 11<br />
D. Hardiman 2425 94th Ave #3 X Asia Hardiman 3/5/2001 1<br />
REGINA ANDERSON 2425 94TH AVE #4 X Sherry Harvey 3/1/1993 8<br />
JANICEE HAWKINS 2425 94TH AVE #1 X Janeisha Hawkins 1/14/1996 6<br />
JANICEE HAWKINS 2425 94lh Ave #1 X Kenneisha Hawkins 612/1991 10<br />
LYDIA HANKINS 2527 21s1 Ave #1 X Oe'Janee Heard 3/30/1995 6<br />
Corey Hunter/ALETA STOWER 880 45th St #1 X Dante Hunter 2/5/1990 12<br />
TOM IEMNOUCHENG KOU 565 29th st #7 X Kevin lem 4/21/1996 6<br />
This is to certify that the information shown under columns (4) and (5) 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) of the foregoing sheet(s) is correct for the person listed under Column (1)<br />
on the survey date. on the survey date.<br />
Signature Date Signature Date<br />
Title Agency Title School District<br />
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).<br />
This form must be signed and dated for this school district to receive funds based on this information.<br />
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