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Impact Aid Program Source Check Form Extract<br />
The survey date is December 11,2007.<br />
Federal Properly: CA003055 Address: 3265 PRENTISS ST<br />
(1) (2) (3) (4) (5) (6) (7) (8)<br />
ParentiGuardian's ParentiGuardian's Branch of Service ParentiGuardian ParentiGuardian Name of Pupil Living With Pupil's Pupil's<br />
Name Address (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) ParentiGuardian <strong>In</strong> 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 />
LienTran Huynh 3265 Prentiss St #B X Sophia Ho 9/18/1993 9<br />
Ulyess WalkerlYolanda Walker 2381 E 21st St #4 X Joanna Hoston 5/9/2000 2<br />
ANNIE JONES 2381 E 21ST ST #2 X Marcel Jones 7/14/1990 11<br />
BINH LE / HANGUYE LE 2381 E 21ST ST #1 X Anthony Le 8/211992 9<br />
BINH LE 2381 E 21ST ST #1 X Anna Le Nguyen 10/26/1996 6<br />
Number Students At This Property 5<br />
This is to certify that the infonnation shown under columns (4) and (5)<br />
olthe foregoing sheet(s) Is correclfor the person listed under Column (1)<br />
on the survey date.<br />
This is to certify that the infonnation shown under columns (4) and (5)<br />
olthe 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 fonn must be signed and dated for this school district to receive funds based on this infonnation.
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