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Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
FederalProperty: CA003001 Address: PERALTA<br />
(1) (2) (3) (4) (5) (6) (7) (8)<br />
ParentlGuardian's ParentlGuardlan's Branch of Service ParentlGuardian ParentlGuardian Name of Pupil Living With Pupil's Pupil's<br />
Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) ParentlGuardlan <strong>In</strong> 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 />
Dorothy Williams 1264 8th St X Selena Williams 11/26/1995 6<br />
Latonya Dean 825 UNION ST #K X Monique WILSON 11/1011997 5<br />
Tyisha Wri9ht 914 Mandeia Pkwy X DESHAWN WRIGHT 11/15/1998 3<br />
TILLIS WRIGHT, TYISHA M. 914 Mandela Pkwy X JORDAN WRIGHT 7/10/2000 2<br />
Tyisha Danzy 1372101h St X Tyllea Antoine' Young 9/24/2000 3<br />
Number Students At This Property 103<br />
This Is to certify that the <strong>In</strong>formation 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 />
This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />
olthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />
on the survey date.<br />
Signature Date Signature<br />
Date<br />
Title Agency Title<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 information.
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