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Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
FederalProperty: CA003059 Address: 368 62ND 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 (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> 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 />
Nemarsha Jack 368 62ND ST 115 X Charles Anderson 1/1/1998 3<br />
NNEMARSHAJACK 368 62ND ST 115 X Kapree Anderson 12/2/1999 2<br />
SABRINA VALLIER 368 62ND ST #4 X Dasja Bates 12/9/1992 10<br />
SABRINA VALLIER 368 62ND ST #4 X Eric Bates 7/1111990 11<br />
MONIQUE BELL 3000 E 18TH ST#6 X Hassani Bell 10/17/1997 5<br />
Cornelius/Helen Bracken 1500 38th Ave #1 X Myaisha Bracken 9115/1991 11<br />
Maurlce & Jaoklshala Bright 9703 Cherry St #2 X Maurice Bright Jr 4/24/2002 0<br />
PRISCILLA GARCIA 1120 BELLA VISTA AVE #3 X Angelena Brissolese 9/20/1996 5<br />
Priscilla Garcia 1120 Bella Vista Ave #3 X Cerena Brissolese 1/19/2000 2<br />
CLAYTON, MYRTIS BUTTRAM 2228 48TH AVE #5 X Calijah Buttram 5/9/1999 3<br />
MYRTIS BUTTRAM 2228 48TH AVE #5 X Clayton Buttram 11/9/1997 5<br />
Buttram, Myrtis/Buttram Jr., Clay 2228 48th Ave 115 X Kalaysia Buttram 9/24/2002 0<br />
Janet Clark 1726 38th Ave #3 X Lavante Cervantes 7/1/1994 7<br />
CHARLA GARY/M. Collins 368 62ND ST 115 X MARYAH COLLINS 6/2612002 0<br />
This Is to certify that the inlonmation shown under columns (4) and (5)<br />
of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />
on the survey date.<br />
This is to certify that the infonmatlon shown under columns (4) and (5)<br />
of the 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<br />
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 form must be signed and dated for this school district to receive funds based on this <strong>In</strong>formation.
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