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 LINDENST
(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
SOUKCHANH SOURYASAK 2239 Linden SI X Cathleen Souryasak 4nJ1990 12
DENISE TUGMAN 2236 CHESTNUT ST X Johnathan Tugman 1/28/1994 8
Tasha Tugman 2236 Chestnut St X Michael Tugman 3/26/1996 6
FENGX. YU 2241 Linden SI X Amy Wen 8/19/1996 6
OIUJIAWEN 2241 LINDEN ST X Xing Hua Wen 6/18/1991 11
Ureka Rose/Edna McCullough 2248 Chestnut St X Torrianna Wilson 8/10/2001 1
Ladonna Dromquole 2311 LINDEN ST X Roy Woodrow 6/29/1997 5
Number Students At This Property 35
This Is to certify that the information shown under columns (4) and (5)
of the foregoing sheet(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)
of the foregoing sheet(s) Is correct for 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.