File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
Federal Property: CA003050 Address: 1853 38TH AVE
(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
MARSHAE LOVELY 3350 72ND AVE #4 X Miya Thrower 2/1611991 9
ALICIA SPEARS 3330 72nd Ave #4 X Terry Walker 5/24/1995 7
Christen McClendon 2309 98th Ave #2 X Xavion Young 4/4/1999 3
Number Students At This Property 45
This is to certify that the infonnalion shown under columns (4) and (5)
of the foregoing sheet(s) is correct for the person listed under Column (1)
on the survey date.
Thts Is to certify that thelnfonnation shown under columns (4) and (5)
of the foregoing shaet(s) Is correct for the person listed under Column (1)
on the survey date.
Signature Date Signature Date
Title Agency Title School District
This Infonnatlon 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.