File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
Federal Property: CA003063 Address: 656 53RD 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
Marian Bennetu Ramon White 873 32nd St #3 X Staranna Hogue 8/20/2000 1
LATOYA LEWIS VARNEDOE 565 45TH ST #4 X CLARYCEJEFFERSON 8/5/2002 0
LATOYA LEWIS VARNEDOE 565 45th St #4 X ISAIAH JEFFERSON VARNED 5/21/2001 1
RACHEL MCDONALD/KEITH J 3217 WEST ST #5 X Kiyana Jones 7/15/1992 10
Laronda Letishe Foster / Chartes 873 32nd St #5 X Chertsh Joseph 4/27/2001 1
Christina Ferrara 987 63rd St #5 X Cordell Joseph 10/4/1990 11
Rachel McDonald/Anthony McMi 3217 West St #5 X Esean Kelly 12/31/1993 7
Debra George 950 40TH ST #7 X Rayshawn Lawrence 7/22/1998 3
RASHONDA WILSON 873 32ND ST #7 X Da'Shawn Lee 4/23/1998 4
VEATTA PHILLIPS/ANNIE PHIL 666 53RD ST #8 X Mon'ALewis 11/28/1991 10
MARGIE CROSBY 6309 Baker St #3 X Jazmine Lincoln 10/11/1997 4
MARGIE CROSBY 6309 Baker St #3 X Rushonda Lincoln 5110/1994 7
VIRGINIA LLOYD 2308 96TH AVE #7 X Charnique Lloyd 7/2/1988 12
Guadalupe-Saul Longinos 950 40th St #1 X Manuel Longinos 11/25/1999 3
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)
of the 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.