File In No. tJ ~- 6 Obb

Federal Property:
Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
CA003001 Address: PERALTA
(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 survey date survey date
YES I NO YES I NO
JENNIFERLY 1378 10TH ST X Rexile Dayrlt 3/5/2001 1
LESHAWN YOPACK 137110TH ST X Anthony Flournoy 1/211990 10
JIMMIE NELL GADSON 138310TH ST X Andra Gadson 6/30/1991 11
KAREN D MITCHELL 136510TH ST X David Gaspard 3/5/1994 7
CHRISTINE HOLMANI MARIA 814 Poplar Way X Mylea Holdman 9/1/1998 4
VALERIE HALE HOLYFIELD 1108 Mandela Pkwy X Terrence Holyfield 1/29/1993 9
DORETHA GIBSON 1108 MANDELA PKWY #A X Darylnlsha Irvin 8/9/1993 9
Comelita DavislDominlque Irving 822 Kirkham Way
X Zynique Irving 1114/2002 0
CONTESSA M. FRANCO 136712TH ST X Catalina Jackson 4/26/1998 4
Rikeisha Seward 1365 12th St X Jabaree Jenkins 12124/2000 1
RIKEISHIA T. SEWARD 136512TH ST X Joven Jenkins 1/28/1998 4
CONSTANCE JOHNSON 825 UNION ST #L X Henry Johnson 7/30/1994 8
Contessa Mendoza Franco/Jess 1367 12th 51
X Adrian Jones 8/30/2002 0
A1aune Butler 829 POPLAR WAY X Alaunte Keys 8130/1999 3
This is to certify that the information shown under coiumns (4) and (5)
of the foregoing sheet(s) is correct for the person listed under Coiumn (1)
on the survey date.
This is to certify that the information shown under columns (4) and (5)
olthe foregoing sheet(s) Is correct for the person listed under Column (1)
on the survey date.
Signature Date Signature Date
Titie Agency
Title School District
This Information Is the basis for payment to this schooi 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 information.