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Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
FederalProperty: CA003076 Address: 1127 FOOTHILL BLVD<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 <strong>In</strong> 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 />
YVONNE BROWN 1127 FOOTHILL BLVD #303 X Myelsha Alexander 5/24/1991 11<br />
CHRISTY GOUDEAU 1127 FOOTHILL BLVD #103 X Rafael Amezquita 1/26/1997 5<br />
JUANA RODRIQUEZ 160811TH AVE #16 X Brenda Bautista 9/4/1992 10<br />
JUANA RODRIQUEZ 160811TH AVE #16 X Elisa Bautista 10/7/1995 6<br />
GWENDOLYN SMITH 1127 FOOTHILL BLVD #101 X Shalandus CaUp 1/1111995 7<br />
Tomico Anderson 1127 Foothill Blvd #203 X Kevin Davis 1111/1992 9<br />
Phalla Din 1606111hAve#14 X Paulina Din 12119/2001 0<br />
LUN ENG 160611TH AVE #14 X Ratlay Din 1/3011998 4<br />
LUMENG 1606 11TH AVE #14 X Vanaka Din 1/13/1994 8<br />
GWENDOLYN SMITH 1127 FOOTHILL BLVD #101 X Davian Dunwood 214/1999 2<br />
TONYA LANCASTER 1608111h ave #18 X Javaris Holmes 11/2211994 7<br />
TONYA LANCASTER 160811thAve#18 X Jayvier Holmes 21811997 5<br />
TONYA LANCASTER 1608 11th Ave #18 X Jordan Holmes 7/7/1998 4<br />
TONYA LANCASTER 1608111hAve#18 X Joshilyn Holmes 1/30/1996 6<br />
This Is to certify that the <strong>In</strong>fonnatlon shown under columns (4) and (5) This is to certify that the infonnation shown under columns (4) and (5)<br />
ofthe foregoing sheet(s) Is correct for the person listed under Column (1) of the foregoing sheet(s) is correct for the person listed under Column (1)<br />
on the survey date. on the survey date.<br />
Signature<br />
Date Signature Date<br />
Title Agency Title School District<br />
This <strong>In</strong>fonnation 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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