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Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
Federal Property: CA003001 Address: PERALTA<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 />
Shert Williams/Jerome McElroy 1385 10lh SI X Jermya McElroy 5/211996 6<br />
Marisol Melendez 1108 Mandela Pkwy #G X Isis Melendez 1/2211999 3<br />
Felicia & Walter Mira 137112TH ST X Michelle Mira 215/1997 5<br />
Maisha Selmon/Andre Morris 12588th SI X Alalzha Morris 10/6/2001 1<br />
KIM JOHNSON 138610TH ST X Jorrail Manis 10/15/1997 4<br />
Valerte Holyfield 1108 Mandela PKWY X Me'Kaiian Murray 7/5/2002 0<br />
Valerie Holyfield 1108 Mandela Pkwy X Melvin Murray 8/1212000 2<br />
CATHY BROWN/DEBRA 938 Poplar CI X Clifford Nivens 11/2211993 9<br />
SHARON DEMEUSE 837 KIRKHAM WAY X Tori O'brien 3/27/1998 4<br />
SOPHALOK 835 KIRKHAM WAY X David Ok 9/18/1989 12<br />
LYOM 826 MANDELA PKWY #A X AmmaraOm 2114/1994 8<br />
LYOM 826 Mandela Pkwy #A X Rani Om 211/1992 9<br />
JERRY DEAN THOMAS 1370 10TH ST X Joyce Omlniona 1/13/1992 10<br />
Angena <strong>No</strong>rman 825 Union SI X Demonic Palmer 10/612001<br />
This is to certify that the information 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<br />
This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />
ofthe foregoing sheet(s) is correcllor the person listed under Column (1)<br />
on the survey date.<br />
Date Signature Date<br />
Title Agency Title School District<br />
ThiS information is the basis for payment to this school district of federal funds under the Impact Aid Program (Titie VIII of the 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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