File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
Federal Property: CA003062 Address: 920 62ND ST
(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
KIMBERLY CASEY 365 49TH ST #4 X Ira Haley 6/6/1998 4
JUANITA LIPSEY 5805 CANNING ST #3 X Diamond Hardaway 6/12/1993 9
SEBRENA FLENNAUGH 361 49TH ST #2 X James Hines IV 3/5/1996 6
SEBERENA FLENNAUGH 361 49TH ST #2 X Kejaney Johnson 1/31/1993 10
ELIZABETH LEE 648 57TH ST #5 X VyLe 8/111993 9
Anne Lavonne Amons 365 49th St #1 X Deonta Martin 7/7/1991 11
Cassandra Barranlo 3017 West St #3 X Valleesha Matthews 5/17/2001 1
BETTY JOHNSON 2995 School St #5 X Tatyana Mccoy 11/12/1994 8
ALEISHA WASHINGTON 3025 MARTIN LUTHER KING J X Calvin McRay 1/24/1995 7
STARLET ROBINSON 365 49TH ST #6 X Dashanea Morrow 1/21/1994 8
STARTLET ROBINSON 365 49TH ST #6 X Deserea Morrow 1/21/1994 7
Sebrena Flennaugh 361 49th St #2 X Delvahn Mosley-Davis 8/24/1994 7
CHERICE EARBY 365 49Jh St #4 X Kennedy Mullins 2/6/1992 10
KAYASIBLEY 4516 Fairfax Ave #1 X Dureana Murphy 6/16/1995 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.
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 Date Signature Date
Title Agency
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.