File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
FederalProperty: CA003067 Address: 2155 E 28TH 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
DENITA WILLIAMS 6631 LAIRD AVE #1
Denita Williams
6631 Laird Ave #1
Number Students At This Property 16
This is to certify that the infonnation 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
YES I NO YES I NO
x
X
Raimon Williams
Tiana Williams
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 Date
Title Agency
Title School District
11/18/1999
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.
7/1/1995
2
7