File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11,2007.
Federal Property: CA003077 Address: 4100 ALLENDALE AVE
(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
TAMERA DANIELS 4100 Allendale Ave #2 X T'ReliAdams 11/4/1995 7
Bernadine Russ/Dwayne butler 4068 ALLENDALE AVE #5 X Aryannah Butler 6/27/1991 11
BERNADINE BUTLER 4068 ALLENDALE AVE #5 X Dwayne Butler 6/23/1998 4
KENYA SMITH-EDWARDS 1458 52ND AVE #1 X Kemari Edwards 11/28/1996 6
KERAMOZON 10221 STANLEY AVE #3 X Tayuan Lubin 3/9/2002 0
georgina vazzie 3590 Lincoln Ave #4 X maricela martin 6/25/2001 1
LINDA SANDIFER 3590 LINCOLN AVE #3 X Aaron Oakes 8/2211990 11
ANGELA JAMES 2439 E 21ST ST #1 X Mikianna Thompson 6/25/1996 5
BRIANNA MORTON 3590 LINCOLN AVE #2 X Lawrence Vickers 12131/1992 8
GERALDINE CAMPBELL 2439 E 21st St #1 X Damon Williams 11/10/1992 9
Number Students At This Property 10
This is to certify that the Information shown under columns (4) and (5)
oflhe foregoing sheet(s) is correctforthe person listed under Column (1)
on the survey date.
This is to certify that the information shown under columns (4) and (5)
oflhe foregoing sheet(s) is correctfor the person listed under Column (1)
on the survey date.
Signature Date Signature
Date
Title Agency Tille
School District
This Information 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.