File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
Federal Property: CA003001 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 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
Shawn Shannon 844 Mandela Pkwy #F X zamani Shannon 12124/1995 6
CLAUDIE ATKINS 915 Union St #A X AUjee Shephard 3/16/1993 8
Denina Denard 834 Poplar Way X Ciara Smith 2fl/2000 2
TOMIKA HENRY 136710TH ST X Erianna Smith 8/8/1996 6
RACQUELFOSTER 825 Union St #F X Hassa Smith 10/2812001 1
JASON SMITHfTANYKA FRYE 1108 Mandela Pkwy X Ja'Lynn Smith 12124/1999 3
Frye TanykalJason Smith 1108 Mandela Pkwy X J'den Smith 5/1212002 0
Denina Denard 834 POPLAR WAY X Leeahna Smith 7/30/1998 4
Felicia Jones 836 Poplar Way X Travelle Smith 11/1211990 9
ANDRE SMITH 841 Poplar Way X Xavier Smith 1/20/1996 5
Marisol Melendez 1108 Mandela Pkwy #G X Desiree Smyth 1/4/1997 5
SOUKCHANHSOURYASAK 828 Poplar Way X Chrtstopher Souryasak 5/24/1993 9
Tieisha Jackson 834 Kirkham way X Marshawn Sylvester 8113/2002 0
Jamie Davis 838 Mandela Pkwy X Jezikiah Talton 213/1999 3
This Is to certify that the Information shown under columns (4) end (5)
ofthe foregoing sheet(s) is correcttor 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 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.