File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11,2007.
FederalProperly: CA003068 Address: 5125 MARTIN LUTHER KING JR WAY
(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
Laquida Prall 5125 Martin Luther King Jr Way X ErishaAdams 3/18/1991 9
TAWANDAJACK 5125 MARTIN LUTHER KING J X Le'Mondre Bailey 11/17/1994 8
TAWANDAJACK 5125 MARTIN LUTHER KING J X Shinena Bailey 3/3/1998 4
Carla Patterson 3855 Shafter Ave #3 X Delontae Bellamy 7/212000 2
Sylvia Burks 2943 NICOL AVE #3 X Dalorrein Burks 7/15/1990 12
Brandi Pratt 5125 Martin Luther King JrWay X Katrina Butler 4/19/1994 8
Bessie Mae Barnes 5125 Martin Luther King Jr WAY X Myleke Byers 1/16/1999 3
BESSIE BARNES 5125 MARTIN LUTHER KING J X Octorta Byers 5/14/1991 11
VANNY LAN 1305 E 25TH ST #D X John Carson 11/19/1990 11
VANY/RICHARD CARSON 1305 E25th St#D X William Carson 6/25/1992 10
Yolanda Thomas 2943 Nicol Ave #5 X Danielle Dunham 3/29/1994 8
Martinesha Gilberti Jabart Gilber 1305 E 25th St #B X Brtaja Gilbert 5/5/2002 0
Teresa B. Kennedy 2943 Nicol Ave #5 X Jerron Grant 5/23/1997 5
Henry, Eda 5125 Martin Luther King Jr Way X Lahoma Henry 7/212002 0
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
This is to certify that the Information shown under columns (4) and (5)
olthe foregoing sheet(s) is correclfor the person listed under Column (1)
on the survey date.
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.