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(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 />
Chemerry Bazile<br />
VANESSA GRUBB<br />
Hoa Tran/Kimyen Nguyen<br />
Impact Aid Program Source Check Form Extract<br />
The survey date is December 11,2007.<br />
Federal Property: CA003082 Address: 1089 26TH 8T<br />
1089 26th St#113<br />
1089 26TH ST#126<br />
1089 26th St#321<br />
Number Students At This Property = 31<br />
Total Number Students = 1,382<br />
YES I NO YES I NO<br />
x<br />
X<br />
X<br />
Mantell Cornell Smith<br />
Joseph Thomas<br />
Quochuy Tran<br />
This is to certify that the information shown under columns (4) and (5)<br />
of the foregoing sheet(s) Is corr ct f th person listed under Column (1)<br />
on the survey dat<br />
Chief Financial Officer<br />
Title<br />
e<br />
1/28/08<br />
1/2/2002<br />
11120/1991<br />
2120/1990<br />
Oakland Unified School District<br />
School District<br />
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).<br />
This form must be signed and dated for this school district to receive funds based on this <strong>In</strong>fonnation.<br />
o<br />
9<br />
10
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