File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11,2007.
Federal Property: CA003075 Address: 6130 HILTON ST
Signature
(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 surveydaie survey date
YES I NO YES I NO
Sandra Williams 3295 Lynde St #7 X Dejanay Ryan 1/1011998 3
Latonia D. George 3291 Lynde St #8 X Dominique Samuels 7/17/1998 4
DEANNA JOHNSON/ORLANDO 1135 63RD ST #6 X Alandra Smith 7/8/1992 9
JACQUELINE/SAMUEL SMITH 4203 TERRACE ST #2 X Janina Smith 1/1911993 9
FELICIA STEPHENS 582 48TH ST #1 X Lydell Smith 7/11/1997 4
FELICIA STEPHENS 582 48TH ST #1 X Rhalani Smith 8/15/1998 4
Melissa Tuggles 1130 62nd St#1 X Shaun Stanford 9/22/1999 2
LAWANDA MARTIN 4203 TERRACE ST #1 X Dani Tarver 8/14/1998 4
LAWANDA MARTIN 4203 TERRACE ST #1 X Danielle Tarver 9/1311996 6
MARY DEMOLLE 6238 Seminary Ave #4 X Marquise Usher 12/13/1989 12
Lagashia Williams 4203 Terrace St #4 X Kahleec Vauqhn 7/9/1998 4
Nathaniel Ward 827 52nd St #3 X Brittney Ward 10/26/1994 7
DEBRA WARD 113163RDST#11 X Kierra Ward 5/12/1992 10
DONELLA HODGESjames 6238 SEMINARY AVE #3 X Damon Watkins 7/27/1994 7
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
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.
Title Agancy 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 infonnation.
Date