File In No. tJ ~- 6 Obb

Federal Property:
Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
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
Lashon Tyson 840 POPLAR WAY X
or above property above property
Foreign Military as of as of
Government survey date survey date
YES I NO YES I NO
Daejuanay THOMAS 1/4/1995 7
REGINA THOMAS 840 KIRKHAM WAY X James Thomas 3/19/1990 10
Cathy Brown/Keith Thomas 938 Poplar CI X Marontay Thomas 7/31/1991 11
CATHY BROWN 938 Poplar CI X Marquis Thomas 7/26/1990 12
JOY TRENT 1373 10lh SI X
Jacari Trenl-Pontoon 3/23/1997 4
MONACHA 136610TH ST X Nathan Tsui 12111/1997 4
Latisha Bryant 940 Poplar Ct X TaijahTumer 9/13/2000 2
Slacy Ricardl Kevin Valentine 825 Union 51 X
Dy'lon Valentine 1/2112002 0
Doretha Gibson 1108 MANDELA PKWY #A X Michael Warrick 9/14/1990 10
Agnes Warrick 1108 Mandela Pkwy #A X
keisha honeywood 826 Mandela Pkwy #e X
Roger Warrick 10/10/1990 10
Dwayne Washington 8/21/2000 2
BOBBIE MCCULLOUGH 824 Poplar Way X Kimiesha Whiteside 1211211990 10
Dorothy Williams 1284 8th 51 X
Cordell Williams 4/17/2001 1
GAIL SMITH 1108 POPLAR LN X Rondrea Williams 1/2211992 9
This Is to certify that the information shown under columns (4) and (5)
oflhe foregoing sheet(s) is correct for the person listed under Column (1)
on the survey date.
Signature Date Signature
Tille
Agency
This is to certify that the information shown under columns (4) and (5)
oflhe foregoing sheet(s) is conrect for the person listed under Column (1)
on the survey date.
Title
Date
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.