File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
Federal Property: CA003082 Address: 1089 26TH 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
CHEMERRY BAZILE 1089 26TH ST #113 X Shamire Bazile 1/7/1998 4
SONJI D FORT 1089 26TH ST #136 X Jasmine Beverly 12124/1989 12
SONJI FORT 1089 26th St #136 X Shonise Beverly 11/26/1991 11
Chemerry Bazile 1089 26th St #113 X Tierra Blake 4/17/2000 2
Solomon Feleke/Debra Feleke 1089 26th St #132 X Mekyle Feleke 1/1012002 0
Debra Feleke 1089 26th St #132 X Melaak Feleke 5/211999 3
Vickie Liu 1089 26th ST #213 X Willie Feng-Liu 11/14/2001 1
Sonja Port 1089 26th ST #136 X Sontaceec Garza 8/212002 0
GRUBBS, VANESSA 1089 26TH ST #126 X James Grubbs 4/811990 12
Vanessa Grubbs / James Ferrell 1089 26th St #126 X Jacob Hall 12119/1993 7
Annemarie Johnson 1089 26TH ST #128 X Ashley Johnson 9/26/1996 6
ANNA MARIE JOHNSON/Arthur 1089 26TH ST #128 X LaDonna Johnson 7/30/1992 9
Qasim KhalaqilJawhara Ahmed 1089 26th St #127 X Ali Khalaqi 11/3/1995 5
Qasim KhalaqilJawhara Ahmed 1089 26th SI #127 X Arsalan Khalaqi 3/17/1998 4
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
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.
Date Signature Date
Title Agency Title School District
This Information Is the basis for payment to this SChOOldistrict 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.