File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
Federal Property: CAO03001 Address: PERALTA
(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 Coiumn (1) Parent/Guardian in Date of Grade
if applicable) ilved on worked on Column (1) Birth
or above property above property
Foreign Mllitary as of as of
Government survey date survey date
YES I NO YES I NO
ANGELA NORMAN 825 UNION ST X Duwan Palmer 3/9/1993 8
ANGELA NORMAN 825 UNION ST X Duane Palmer Jr 4/4/1992 9
Decola Pearson 845 Union SI X Jada Pearson 7/8/2000 2
DOREEN HODGES 1006 POPLAR WAY X Michael Peters 4/28/1990 12
Kendra Brewster/ Ali Polk 825 Union St #H X Jalen Polk-Brewster 6/212002 0
TUYET LE 1108 MANDELA PKWY #D X Jenni Quai 2124/2002 0
Kenya Anthony 1105 POPLAR LN X Frenswa Raynor 3/27/1997 4
Jerico RobertsoniKhaliiah Brace 906 Poplar Way X Jaleel Robertson 11110/1999 2
Jerico Robertson Sr/Khalilah Bra 906 Poplar Way X Jerico Robertson Jr 4/16/2002 0
Melinda Ross 826 KIRKHAM WAY X Acacia Ross 2127/1998 4
SamboSao 900 Kirkham Way X Christian Sao 9/14/2002 0
Slacy Richard 825 UNION ST X Angel Searcy 2128/1998 4
CARLEITA COBB 936 POPLAR CT X Quanisha Secrease 7/7/1992 9
DARIKA BATES/EVA SHANNO 844 MANDELA PKWY #D X Shanequia Shannon 10/3/1991 11
This is to certify that the infonmatlon 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 thelnfonmatlon shown under columns (4) and (5)
ofthe foregoing sheet(s) is correclfor the person listed under Column (1)
on the survey date.
Signature Date Signature Date
Tille Agency
Title School District
This Infonmatlon 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.