File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
Federal Property: CA003068 Address: 5125 MARTIN LUTHER KING JR WAY
(1) (2) (3) (4) (5) (6) (7) (8)
ParentiGuardian's ParentiGuardian's Branch of Service ParentiGuardian ParentiGuardian Name of Pupil Living With Pupil's Pupil's
Name Address (including rank, In Column (1) In Column (1) ParentiGuardian 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
CARLA PATIERSON 3855 Shafter Ave #3 X Destinee Hodges 8/21/1993 8
TANYA HOWARD 3855 SHAFTER AVE #4 X Quincie Howard 1/3011997 5
Latreece Camp 211538thAve#3 X Ja'Monie Johnson 11/23/1998 4
Camell Perry 5125 MARTIN LUTHER KING J X Zakari Perry 11110/1997 5
CARNELL PERRY 5125 MARTIN LUTHER KING J X Zerenna Perry 9/7/1995 7
Emerald Hallman 2943 Nicol Ave #2 X Aries Pierce 9/27/1998 6
Lateesha Perkins 2110 25th Ave #2 X Linda Scruggs 7/26/2000 1
ERSHELL LOVE (UNCLE) 2115 38TH AVE #1 X Latasha Smith 9/1911990 10
TANYA HOWARD 3855 SHAFTER AVE #4 X JOEMARTATE 2117/2001 1
Brandy West 3855 Shafter Ave #1 X LaTavia West 9/16/2000 1
Number Students At This Property 24
This Is to certify that the Informetlon 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)
ofthe foregoing sheet(s) Is correct for 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.