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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, in Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />
if applicable) lived on worked on Coiumn (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 />
TONYA LANCASTER 160811th ave #18 X Michael Holmes 1/7/1994 7<br />
ALISON BRODNAX 1610 11TH AVE #8 X Rodney Homage Jr 3/611991 10<br />
LE BE& RO NGUYEN 160811TH AVE #15 X Hon9 Le 5/4/1991 10<br />
BE LEiRO NGUYEN 160811TH AVE #15 X Peter Le 9/1011994 8<br />
Mary McLane 160611thAve#13 X Erica Miller 2124/1993 8<br />
DUNG NGUYEN 1127 FOOTHILL BLVD #204 X Donna Nguyen 9/211993 9<br />
tanya lancaster 160811thAve#18 X Jacarf Pearson 3/14/2001 1<br />
Tosha White 1127 Foothill Blvd #102 X Genal Reliford 2123/2001 1<br />
TOSHAWHITE 1127 Foothill Blvd #102 X George Reliford 3/29/1998 4<br />
Latonya Shivers 160811thAve#17 X Isaiah Rice 1/13/2002 0<br />
Roxchell Santee 1610 11th Ave #8 X Tyree Santee 9/27/1995 6<br />
Yvonne Brow 1127 Foothill Blvd #303 X Kevin Taylor 121212001 0<br />
BINH VU & THUY TRAN 1610 11TH AVE #4 X <strong>In</strong>finity T18n 4/1/1999 3<br />
Shante Dennis/Sheila Davis 160611thAve#11 X Dalaijah White 3/9/2001<br />
This Is to certify that the <strong>In</strong>lonmatlon shown under columns (4) and (5) This is to certify that the <strong>In</strong>fonmatlon shown under columns (4) and (5)<br />
of the 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 Date Signature Date<br />
Title Agency Title<br />
School District<br />
This <strong>In</strong>formation 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 <strong>In</strong>formation.
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