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
Signature
(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
CHRISTIYA TAYLOR 920 62nd St #1 X Canington Taylor 12/13/1994 6
Constance Hannibal & Lynn Rix 3017 West St #5 X Da Shawn Taylor 12/14/1996 4
CONSTANCE HANNIBAL 3017 West SI #5 X Dajanne Taylor 6/14/1993 8
CONSTANCE HANNIBAL 3017 West St #5 X David Taylor Jr 111111995 6
Cora Wilcots/Precious Butler 3017 West SI #1 X Robbie Thompson 5/11/2002 0
Warner Eland Dwan Walker 365 49th St #7 X D'Montay Warner 311812002 0
RENITA WESSON-JONES 3025 Martin Luther King Jr Way X ROMERO WESSON 5/17/2001 1
Anne Amons 365 49th St #1 X Ericka Wright 2/23/1993 9
SAKHOEUTH YAV/KIMSORY L 680 55TH ST#A X SandyYav 10/27/1992 10
Number Students At This Property 51
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
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.
Title Agency Title School District
This Information Is the basis for payment to this school dlstrtct offederal funds under the Impact Aid Program (TItle VIII ofthe Elementary and Secondary Education Act).
This form must be signed and dated for this school district to receive funds based on this Information.
Date