File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
Federal Property: CA003063 Address: 65653RD 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
Margie Crosby 6309 Baker St #3 X Margertta Williams 3/1/1993 9
MARGIE CROSBY 6309 Baker St #3 X Naomi Williams 2/3/1992 10
Emanuel Worthington 950 40TH ST #8 X Jantelle Worthington 1/25/1992 9
Number Students At This Property 73
This Is to certify that the Infonnatlon 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
This is to certify that the Infonnatlon shown under columns (4) and (5)
of the foregoing sheet(s) Is correct for the person listed under Column (1)
on the survey date.
Title Agency Title School District
This infonnation 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.
Date