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Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
Federal Property: CA003081 Address: 2323 LINDEN ST<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, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />
If applicable) lived on worked on Column (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 />
LADONNA DROMGOOLE 2311 LINDEN ST X Bra King 9/29/2002 0<br />
MONICA WILSON 2237 LINDEN ST X Jamon Morton 7/18/1991 10<br />
EDNA MCCULLOUGH/Ureka Ro 2248 CHESTNUT ST X Gerureka Price 10/2811995 7<br />
ANTOINEITE SANDERS 2318 CHESTNUT ST X DEVIAN PRYOR 218/2001 1<br />
TASHA TUGMAN 2236 CHESTNUT ST X Tommy Ramsey III 11/211991 9<br />
GALENIA GOINS 2237 LINDEN ST X Dessiness Robinson 7/20/1993 9<br />
SOPHENMEY 2239 LINDEN ST X Alena Raeun 5/4/1994 8<br />
EDNA MCCULLOUGH 2248 CHESTNUT ST X Umiika Rose 2120/1997 5<br />
NAKISHA WILLIAMS 2227 LINDEN ST X Michael Roy Jr 10/20/2001 1<br />
ORA BOHANNON 2230 Chestnut St X Marcus Ruben 9/5/1994 7<br />
savann San 2320 Chestnut St X Chansophanin San 10/19/1992 10<br />
Savann San 2320 Chestnut St X Phoummara SAN 3/25/1996 6<br />
Demina Shannon 2249 Linden St X Jordan Shannon 4/23/2001 1<br />
Banho Som/Soknou Sen9 2308 Chestnut St X Pugna Som 8/13/2002 0<br />
This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />
olthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />
on the survey date.<br />
This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />
of the foregoing sheet(s) Is correct for the person listed under Column (1)<br />
on the survey date.<br />
Signature Date Signature Date<br />
Title Agency Title School District<br />
This <strong>In</strong>formation Is the basis for payment to this school district offederal funds under the Impact Aid Program (Title VIII olthe Elementary and Secondary Education Act).<br />
This form must be signed and dated for this school district to receive funds based on this information.
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