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Impact Aid Program Source Check Form Extract<br />
The survey date is December 11,2007.<br />
Federal Property: CA003050 Address: 1853 38TH AVE<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 <strong>In</strong> 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 'r NO<br />
RHONDA WILEY 1853 38th AVE #8 X Hykeem Andrews 3/11/1992 10<br />
LINDA JOHNSON 2820 35TH AVE #10 X Datoine Attaway 8/24/1997 3<br />
LASHANDAJACKSON 2311 98TH AVE #4 X Stajia Benjamin 5/8/1999 3<br />
Pamelyn Bickham 2820 35TH AVE #1 X Adrienna Bickham 7/5/1991 10<br />
Ashley Gonzalez/Brown, <strong>No</strong>ah 2820 35th Ave #13 X Jeremiah Brown 9/21/2002 0<br />
KiVA PORTLOCK & JAMEL BR 1430 SEMINARY AVE #7 X Jamaliah Brown Jr 10/31/1996 6<br />
KAREN SHIVERS 3330 72nd Ave #2 X Serenity Butler 11/20/1996 6<br />
DONALDILASHANDA CAMPBE 1853 38TH AVE #3 X Deshawn Campbell 1/25/1996 6<br />
Danielle Paxton 1853 38th Ave #15 X Patrick Coleman 10/26/1992 9<br />
YOLANDA WILLIAMS 2820 35TH AVE #3 X Jamelle Corbino 7/22/1993 8<br />
Yu Li Li I Jian Zhuang Wu 1853 38th Ave #12 X Jie Ylng Wu Dang 6/15/2001 1<br />
LISA PAGE 2309 98TH AVE #4 X Ha'Keila Fontenette 8/1/1995 7<br />
LISA PAGE 2309 98TH AVE #4 X Xillia Fontenette 11/29/1993 8<br />
TARAH GOODWIN 1430 SEMINARY AVE #8 X Brtttney Goodwin 4/6/1998 4<br />
This is to certify that the information shown under coiumns (4) and (5)<br />
ofthe foregoing sheet(s) is correcttor the person listed under Column (1)<br />
on the survey date.<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 />
Signature Date<br />
Signature Date<br />
Title Agency Title 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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