File In No. tJ ~- 6 Obb

Federal Property:
Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
CA003075 Address: 6130 HILTON ST
(1) (2) (3) (4) (5) (6) (7) (8)
ParenUGuardian's ParenUGuardian's Branch of Service ParenUGuardian ParenUGuardian Name of Pupil Living With Pupil's Pupil's
Name Address (including rank, In Column (1) In Column (1) ParenUGuardian 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
DONELLA HODGES 6238 SEMINARY AVE #3 X Dominique Watkins 10/16/1991 9
CAROLYN CARTER 6126 HILTON ST #4 X Porche Webb 11/811993 9
CAROLYN CARTER 6126 Hilton St #4 X Kiana Wesley 4/211991 10
RITA WILLIAMS 1131 63RD ST #9 X Brianna Williams 9/24/1993 9
JUNAN LUSTER 59 PEARL ST #9 X Teaira Williams 1/30/1990 9
Oneeca Williams 3295 Lynde St #7 X Yvette Williams II 10/13/1992 9
LAURA PATRICK 2000 E 21st St #2 X Latifah Wilson 3/19/1992 10
LAURA PATRICK 2000 E 21st ST #2 X Tashiya Wilson 7/19/1997 5
LAURA PATRICK 2000 E 21st St #2 X T'Shun Wilson 9/1211990 10
ANGELA WIMBERLY 582 48TH ST #2 X Anthony Wimberly 6/24/1989 12
Number Students At This Property 52
This Is to certify that the Infonnatlon 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 Infonnation shown under columns (4) and (5)
oflhe foregoing sheet(s) is correc!for the person listed under Column (1)
on the survey date.
Date Signature Date
Title Agency Title School District
This Infonnation Is the basis for payment to this school district offederal funds under the Impact Aid Program (Title VIII oflhe Elementary and Secondary Education Act).
This form must be signed and dated for this school district to receive funds based on this Information.