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FederalProperty:<br />
Impact Aid Program Source Check Form Extract<br />
The survey date is December 11,2007.<br />
CA003075 Address: 6130 HILTONST<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 />
Atef Mohammed 3293 Lynde St #1 X Alia Mohammed 3/17/1993 9<br />
Judy Speech 59 Pearl St#6 X Daquata Moss 7/25/1990 11<br />
CONSTANCE MENEESE-NELS 59 Pearl St #7<br />
X Anthony Nelson 3/3011993 9<br />
Vickie L. Mohammed 3293 Lynde St #1 X Ghazi Naseir 11/19/1996 5<br />
Atef Mohammed 3293 Lynde St #1 X Layla Naseir 10/19/1998 3<br />
REGINA TURNER 6130 HILTON ST #8 X Charles Payne 11/2211990 11<br />
Harold Phillips 582 48th St #10 X Laron Phillips 9/1211992 9<br />
Chrtstine LeBrane 582 48th St #4 X Keoshi Pritchard 12128/1999 2<br />
Helen A. Johnson I Jerome Jam 3293 Lynde St #5 X Jalauni Range 1/27/1997 5<br />
Helen Johnson 3293 Lynde St #5<br />
X Jemauri Range 1/31/2001 1<br />
Richard. Roland & Crytal Drake 810 60th St #3 X Isaiah Albertino Richard 4/13/2001 1<br />
Crystal/Juanita Drake 810 60TH ST #3 X Jeremiah Richard 5/19/1999 3<br />
Barbie Hall/Latonya Hall 810 60th St #1 X Eboni Route 9114/1994 7<br />
Barbie Hall/Latonya Hall 810 60th St #1 X Essence Route 5/3/1993 9<br />
This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />
of the foregoing sheet(s) is correct for the person listed under Column (1)<br />
on the survey date.<br />
Signature<br />
Date Signature<br />
This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />
of the foregoing sheet(s) is correct for the person listed under Column (1)<br />
on the survey date.<br />
Title Agency 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.<br />
Date
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