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Impact Aid Program Source Check Form Extract<br />
The survey date is December 11,2007.<br />
FederalProperty: CA003056 Address: 9024 CHERRY 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 (including rank, <strong>In</strong> Column (1) in 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 />
YAO KOUEI LEE 2353 E 24TH ST #2 X . Chan Lua Lee 3110/1991 11<br />
ISALUCAS 1951 E 24TH ST #4 X Isaiah Lucas 5/15/1997 4<br />
ODESSIA MATTHEWS(GUARD 1737 E 15TH ST #3 X Tiarra Matthews 5/18/1992 9<br />
JENNY NGO 1944 16TH AVE #1 X Connie Ngo 7/30/1990 12<br />
HOLLYDAO 2017 E 24th St #1 X Trung Due Nguyen 4/23/1993 9<br />
SIPHEAPEAV 1737 E 15TH ST #2 X AbellonaOuk 9/211990 12<br />
SOPHA PHOUNG 1930 16TH AVE #2 X Daliya Phikun 11/18/1996 6<br />
Wilkes, Erin 2017 E 24th St #2 X Malik Riser 9/26/1995 7<br />
Deborah Rice 2353 E 24th St #3 X Fatimah Shahid 1/812001 1<br />
Deborah Rice 2353 E 24th St #3 X Muhammad Shahid 6/211998 3<br />
KEYONA HARDEN 1936 16TH AVE #1 X Isane Smith 7/14/1999 2<br />
Saran Vann 1936 16th Ave #3 X Annie Sou 8/16/2002 0<br />
Robin AndersonlRobert TIpton 2102 E 17th St #A X Kyra Tipton 3119/2002 0<br />
MESHA BRADFORD 1737 E 15th St #5 X Aaron Turner 5/11/1992 10<br />
This is to certify that the information shown under columns (4) and (5)<br />
oflhe 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 />
oflhe foregoing sheet(s) is correct for the person listed under Column (1)<br />
on the sUlVey date.<br />
Signature Date Signature Date<br />
Title Agency<br />
Title School District<br />
This <strong>In</strong>formation 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 <strong>In</strong>formation.
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