File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
Federal Property: CA003054 Address: 2435 26TH 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
Jones Shantee E 2435 26th Ave #2 X Anise Foster 1/9/2001 1
LUPE GANTT O'CON 2435 26th Ave #5 X Anlssa Gantt 8/21/2000 2
MARICHEL TOLENTINO/ Simeo 2435 26th Ave #5 X Jhomarie Manzano 1/28/1995 6
Marichel Tolentino/Simeon Manz 2435 26th Ave #5 X Jhunnie Manzano 2/13/1999 3
PATRICIA BELL 2435 26TH AVE #3 X Patricia Mitchell 9/21/1989 12
Shantee Jones 2435 26th Ave #2 X Gregory Powell 1/11/1995 7
Number Students At This Property 6
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.
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.
Signature Date Signature
Date
Title Agency Title
School District
This information Is the basis for paymentto this school district offederal funds under the Impact Aid Program (TItle VIII olthe Elementary and Secondary Education Act).
This form must be signed and dated for this school district to receive funds based on this Information.