File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11,2007.
FederalProperty: CA003047 Address: 565 29TH 8T
(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
LAKISHA HINES 4118 Lyon Ave #204 X Antione Walker 5/24/1995 6
SCHANIA HUNTER 880 45th 5t #1 X Jessica Ward 11/12/1991 10
Luegenia Weathers 5825 CANNING ST #10 X Slanisha Weathers 7/10/1992 9
Jacqueline Trotter/ JemmyWilso 881 41ST ST #B X Jamika Wilson 8/21/1996 6
JACQUELINE TROTTER 881 41ST ST #B X Jimmy Wilson Jr 1/19/1991 11
Number Students At This Property 61
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.
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.
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