File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
Federal Property: CA003057 Address: 3634 FOOTHILL BLVD
(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 appilcable) i1ved on worked on Column (1) Birth
or above property above property
Foreign Military as at as at
Government survey date survey date
Tuyet Nguyen
LATOSHA Kenard
May Saephan
3634 Foothill Blvd #5
3634 Foothill Blvd #7
3634 Foothill Blvd #10
Number Students At This Property 17
This Is to certify that the Information shown under columns (4) and (5)
ofthe foregoing sheet(s) Is correct for the person listed under Column (1)
on the sURVey date.
Signature
YES I NO YES I NO
x
X
X
Ha Nguyen
Jahleel Phillips
Doneathan Saephan
This Is to certify that the Information shown under columns (4) and (5)
ofthe foregoing sheet{s) Is correct for the person listed under Column (1)
on the survey date.
Date Signature Date
Title Agency Title
School District
10/1711992
7/8/1994
6/20/1995
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.
10
8
7