File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
Federal Property: CA003058 Address: 7510 NEY 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
ARETHA CARON HARRIS 7510 NEY AVE #B X DALLAS BAKER JR 8/26/1990 10
Kenya Smith-Edwards 6650 Laird Ave #D X Mario Edwards Jr 11/1011997 5
Mul Chuong 6650 Laird Ave #C X Jackie Nguyen 4/13/2001 1
SHARLENA RICHARDSON 7510 NEY AVE #E X Mark Richardson 9/29/1990 12
Tammie Rivera 6656 Laird Ave #B X Curtis Smith Jr 4/21/1998 4
Ganya Taylor 7520 NEY AVE #A X Cameron Taylor 3/3/1999 3
JESSIFER JOHNSON 7520 NEY AVE #D X Jacqueline Webster 6/1111998 3
Number Students At This Property 7
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
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.
Date Signature Date
Title Ageney Title
School District
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.