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Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
Federal Properly: 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 />
APRIL M. DURIO 421 OAKLAND AVE #6 X Oayshon Preston 2/17/1993 8<br />
TAMIKAlTRINA RICHARDSON 421 OAKLAND AVE #1 X Tyrone Richardson 6/13/1991 10<br />
CONCEPCION CERNA 881 41st SI #C X Alexander Rico 5/11/1991 9<br />
CONCEPCION CERNA 881 41st SI #C X Rosa Rico 4/2711990 12<br />
THANG SAINGPhaia Ouk 541 29th SI #2 X <strong>No</strong>ra Saing 1/14/1992 10<br />
TAMERACURRINGTON 5120 Shafter Ave #6 X Shannon Scott 1/5/1995 6<br />
SARAH CARR 880 45th SI #1 ·X Quinton Shealey 4/13/1998 4<br />
CYNTHIA COLLINS 565 29TH ST #1 X Andre Smith 9/15/1994 8<br />
CYNTHIA COLLINS/John Jacks 565 29TH ST #1 X Askari Smith 6/13/1996 6<br />
ROZETTA MCCLENDON 541 29TH ST #4 X Desmond SulVine 4/9/1998 4<br />
KENYA MITCHELL 7950 NEY AVE #10 X Kenneth Temple 10/9/1993 8<br />
BARESA BARFIELD 5825 CANNING ST #1 X De'Quan Valentine 11/29/1995 6<br />
HOANGVO 5825 CANNING ST #14 X PhuongVo 2/3/1991 11<br />
HOANGVO 5825 CANNING ST #14 X PhuongVo 2/3/1991 11<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 sheel{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<br />
Signature Date<br />
Title Agency Tille 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 fonn must be signed and dated for this school district to receive funds based on this infonnation.
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