File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
Federal Property: CA003052 Address: 2325 86TH 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 Milltary as of as of
Government survey date survey date
YES I NO YES T NO
SUE JOSEPH 2325 86TH AVE #B X Dakota Biagas 91211994 8
Sue Joseph 2325 86TH AVE #B X Dominique Biagas 112211996 6
Mary Ramirez 2139 Seminary Ave #103 X Rico Febo 312411999 2
ANGELA BALL 2139 SEMINARY AVE #205 X Alycia Filoleo 611011999 3
Vanella Thomton 1815 88th Ave #C X Harinique Halcomb 1211511991 9
SUE LYNCH 2325 86TH AVE #B X Deja Lynch 312411990 11
TRACY KIRKENDOLL 4631 Bond St #0 X Janetria Moore 412111991 11
SHETEKAJOHNSON 2925 E 22ND ST #0 X MAUSE' AH THOMPSON 411512001 1
LYNETIE LAWSON 2325 86TH AVE #0 X Deandre Ward 1111511991 10
Number Students At This Property 9
This Is to certify that the Information shown under columns (4) and (5)
olthe 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.
.Slgnature 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.