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Impact Aid Program Source Check Form Extract<br />
The survey date is December 11,2007.<br />
FederalProperty: CA003074 Address: 3352ARKANSASST<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 in 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 of<br />
Government survey date survey date<br />
YES I NO YES I NO<br />
BENNYBACA 3350 ARKANSAS ST X Paul Baca 6/24/1991 10<br />
SHIRLEY BIRCHETT 1116E15THST X Shykelah Birchett 11/1/1994 8<br />
Barbara FreemanlRuben Crossg 3344 ARKANSAS ST #4 X Ruben Cross 7/19/1999 3<br />
Brian Grayson 1118 E 15th St X Ryant Grayson 2/6/1990 11<br />
Annstead, Myiesha 3346 Arkansas St X Daeshawn Johnson 11/9/2002 0<br />
Minnie Phifer 9232 Bancroft Ave #8 X Jeremy Paul 4/26/1990 12<br />
MYRTIS RANDLE 3344 ARKANSAS ST #3 X Kenneth Redertord 11/5/1997 4<br />
L1VIS(Pam) SANDERS 4825 WEBSTER ST #8 X Ro'Melio Sanders-Combs 8/27/1994 8<br />
RACHON WARRICK 3344 ARKANSAS ST #8 X Anthony Warrtck 2/4/1997 5<br />
ROCHON WARRICK 3344 ARKANSAS ST #8 X Joshua Warrick 1/19/1999 3<br />
TANISHA WHiTE 3346 ARKANSAS ST X Darrion White 3/28/1995 6<br />
Tanisha White 3346 ARKANSAS ST X Zhanaya White 12/4/1996 4<br />
TANISHA L. WHITE 3346 ARKANSAS ST X Daymeioun White-Hamilton 3/23/1999 3<br />
Sharon Wong/John Mitchell 3340 Arkansas St X Chrtstopher Jr Wong 10/30/2001 1<br />
This is to certify that the information shown under columns (4) and (6)<br />
olthe foregoing sheet(s) is correct for the person listed under Column (1)<br />
on the survey date.<br />
This Is to certify that the <strong>In</strong>formation shown under columns (4) and (6)<br />
of the foregoing sheet(s) is correct for the person listed under Column (1)<br />
on the survey date.<br />
Signature Date Signature Date<br />
Title Agency<br />
Title School District<br />
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).<br />
This form must be signed and dated for this school district to receive funds based on this information.
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