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Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
Federal Property: CA003053 Address: 7107 FAVOR ST<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 in 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 I NO<br />
KATHLEEN BROWN 7107 FAVOR ST #4 X Alexus Brown 2117/1995 6<br />
MUANG CHO SAECHAO 2247 E 19TH ST#4 X Farm Chao 8/11/1992 10<br />
SAN WEN SAECHAO 2247 E 19TH ST#4 X Lai Chao 12115/1993 8<br />
Viengkong Ohlthavonq-qrandmot 2247 E 19th St #3 X <strong>No</strong>elani Chithavong 10/15/2002 0<br />
KATHLEEN BROWN 7107 FAVOR ST #4 X Troy Davis 10/24/1989 11<br />
TINA DIXON 2247 E 191hSI #2 X Van Dixon 4/1211993 9<br />
Tanecka Brisbon 2440 E 21ST ST #4 X Sarah Harris 1/13/1992 9<br />
Nicole Wiley 2440 E 21ST ST #8 X Deriyan Johnson 8/18/1998 4<br />
NICOLE WILEY 2440 E 21ST ST #8 X DESIRAY JOHNSON 3/1/2001 1<br />
Vanessa Queen 7107 Favor SI #2 X Tylor Kingsbury 9f712000 2<br />
DONNA OUTING 9320 Sunnyside SI #5 X Keith Jr Livingston 12127/1989 12<br />
Taneka BrisbonlEmeryLowe 2440 E 21st SI #4 X Ashley Lowe 1211112000<br />
LATONYA GROGEN-PENNY 7107 Favor SI #3 X <strong>No</strong>raj Penny 7f711999 3<br />
MEVI (ANGIE) SAECHOW 2440 E 21ST ST #1 X EmllyPhan 12125/1990 10<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 />
This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />
ofthe foregoing sheet{s) Is correct for the person listed under Column (1)<br />
on the survey date.<br />
Signature Date Signature Date<br />
Title Agency Title School District<br />
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).<br />
This form must be signed and dated for this school district to receive funds based on this information.
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