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Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
Federal Property: CA003064 Address: 2474 26TH AVE<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 (including rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> 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 01<br />
Government survey date survey date<br />
YES I NO YES I NO<br />
TAMEKA MUMPHREY 2474 26TH AVE #4 x TAVION JENKINS 8/1812002 o<br />
Number Students At This Property 1<br />
This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />
ofthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />
on the survey date.<br />
Signature<br />
TItle Agency<br />
This Is to certify that the information shown under columns (4) and (5)<br />
ofthe foregoing sheet(s) is correct for the person listed under Column (1)<br />
on the survey date.<br />
Date Signature Date<br />
Title School District<br />
This <strong>In</strong>formation 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 information.
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