File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
Federal Property: CA003078 Address: 537 32ND ST
(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
JOYCE PIERCE 717 43RD ST #2 X Kyle Pierce-Hamilton 9/2211990 11
Juanita Maria Thomas 1905 Seminary Ave #2 X Paul Pills 3/14/2001 1
SHALIMAR MOORE 541 32nd St #6 X Kenyada Whitten 9/24/1995 6
Tanisha Perryman 1915 Seminary Ave #13 X Dejontae Wilson 9/29/2001 0
Tanisha Perryman 1915 Seminary Ave #13 X Elonjanae Wilson-Banks 8/25/2002 0
Number Students At This Property 19
This is to certify that the Information shown under columns (4) and (5)
ofthe foregoing sheet(s) is correclfor the person listed under Coiumn (1)
on the survey date.
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 Column (1)
on the survey date.
Signature Date Signature Date
Title
Agency Titie School District
This information is the basis for payment to this school district of federai funds under the impact Aid Program (Title VIIi of the Eiementary and Secondary Education Act).
This form must be signed and dated for this school district to receive funds based on this Information.