File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
Federal Property: CA003081 Address: 2323 LINDEN 5T
(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
Saba Tesfay 2229 Linden ST X Mekelawit Atakilti 4/3011993 9
ORA BOHANNON 2230 Chestnut St X Orvon Bowen 9/9/1998 4
Tasha Victoria Tugman 2236 Chestnut St X Natasha Dam 7/212001 1
Diane Lee 2238 CHESTNUT ST X Michael Gillis 1/2511998 4
Diane Lee 2238 Chestnut St X Rayn Gillis 8/13/1996 6
Bobby Hamilton 2238 Chestnut St X Avalon Hamilton 2121/1997 5
TASHA TUGMAN 2236 CHESTNUT ST X Danielle Hokes 9/611993 8
TASHA TUGMMAN 2236 CHESTNUT ST X David Hokes Jr 9/6/1993 8
Ureka Rose 2248 CHESTNUT ST X Shawn Holmes 8/14/1994 8
Shi~ey Lee 2238 CHESTNUT ST X Donald Howard Jr. 10/2211997 5
Joleah C Jackson/Seedric L Jac 2319 Linden St X Scedric Jackson Jr 1/25/2002 0
Surenily Johnson/Jenny McDanl 2313 Linden St X Shyianna Johnson 6/7/1998 4
Saba Tesfay 2229 Linden St X Samuel Kassa 4/811997 5
LAURENE KILLIP 2305 LINDEN ST X lesha Killip 10/5/1991 10
This is to certify that the information shown under columns (4) and (5)
of the foregoing sheel(s) is correct for the person listed under Column (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
Title Agency Title 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.