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OMB <strong>No</strong>.1810·0036 Exp.06/3012008<br />
ED 4019 Revised 05/3112005<br />
Table 11. Housing on <strong>In</strong>dian Lands undergoing renovation or rebuilding (Version <strong>No</strong>.1)<br />
Applicant Name: Oakland Unified School District Impact Aid Number: School Year: 2007-2008<br />
14-CA-2009-0430<br />
List of housing located on <strong>In</strong>dian lands undergoing renovation on Impact Aid survey date shown on the cover page of this application by<br />
name, address, and type and identity the number of school-aged children associated with this housing.<br />
(Col. I) (Col. 2) (Col. 3) (Col. 4)<br />
Name (and Number, if Specific Address or Legal Description for Each Type of<strong>In</strong>dian Lands Where Number of School-<br />
Applicable) of Housing House or Unit Undergoing Renovation or Housing is Located(Trust, aged Children Who<br />
Development or Project Rebuilding Restricted, ANCSA, or Other Last Resided in<br />
Undergoing Renovation or Eligible <strong>In</strong>dian Lands) This Housing<br />
Rebuilding<br />
Certification by Housing or Tribal Official: I hereby certify that the information reported above is accurate and that the number of<br />
children listed in colunm 4 would have resided in this housing on <strong>In</strong>dian lands except that the housing was undergoing renovation or<br />
rebuilding on the survey date.<br />
Telephone<br />
Signature Date Name and Title Number<br />
Certification by Bureau of <strong>In</strong>dian Affairs or Tribal Official: I hereby certify that I have reviewed official records and have verified<br />
that this housing is located on <strong>In</strong>dian Lands as defined in sections 8013(5)(A)(ii) and 8013(7) of the Impact Aid Law. (See the application<br />
instructions for definitions.)<br />
I I I ., I<br />
Impact Aid # 140430 e14
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