File In No. tJ ~- 6 Obb

(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
TRAVIS TANKA
TANIKA TRAVIS
TANIKA TRAVIS
Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
Federal Property: CA003076 Address: 1127 FOOTHILL BLVD
160811TH AVE #20
160811TH AVE #20
160811TH AVE #20
Number Students At This Property 31
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.
YES I NO YES I NO
x
X
X
Kalyce Woods
Kyjhae Woods
Kyjhanaa Woods
This Is to certify that the infonnation 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 Date Signature Date
Title Agency Title
School District
1/11/1994
8/22/1995
8/22/1995
This Infonnatlon 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 information.
8
7
7