File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
FederalProperty: CA003066 Address: 1632 E 19TH 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
TERRI GRAVES 5914 COLBY ST #4 X T'Nya Payne 9/19/1997 5
BO CHANG PENGlLin Yue Oin9 1632 E 19th St#6 X Shirley Pen9 10/9/1993 9
BO CHANG PENGILIU YUE 01 1632 E 19th St #6 X Teresa Peng 1/27/1991 11
Chionna Moore 9615 E St #3 X Khamonie Piper 8/2212001
Rhonda Williams 584 58th St #10 X Jaidah Robinson 8/28/2001
CHERYL HOWARD 9615 E St#5 X Leondre Stansberry 8/3/1993 8
Ebony & Maurice Thomas 1632 E 19th St #1 X Kyrah Thomas 3/11/2002 0
Maurice& Ebony Thomas 1632 E 19th St#l X Mariah Thomas 211212000 2
FELICIA GILL 578 58th St #2 X Oeion Tucker 3/25/1991 10
TRELLA WELLS 5914 COLBY ST #3 X Antwaniqua Varello 3/18/1990 12
DONNELL WELLS 5914 COLBY ST #3 X Mykayla Wells 6/14/1994 8
Number Students At This Property 25
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.