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Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
FederalProperty: CA003002 Address: CAMPBELL VILLAGE<br />
(1) (2) (3) (4) (S) (6) (7) (S)<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 />
YES I NO YES I NO<br />
MONICA PARKS 883 Campbell Village Ct X Keonre Belton 12/1/1992 9<br />
Rosalyn Fountain 883 campbell St X Samuel Briggs 3115/2001<br />
ROSALYN FOUNTAIN 883 Campbell St X Tacherla Briggs 9/19/1996 5<br />
JOYCE ROBERTSON 16968TH ST X Tiara Brown 1/9/1999 3<br />
Sel Butlerl Nicole Doman 889 Campbell ST X Sel Butler Jr. 7/1311996 7<br />
LAKESHIA THOMAS 866 WILLOW ST X Elijah Carey 1/22/1998 4<br />
Patricia Austin/Ms. S. Lath 945 campbell St X Passion Carr 7/2611990 10<br />
NATASHA COOPER 890WlllowSt X Zachariah Cooper 5/4/1994 8<br />
HAMMOLEKETH RAMSEY 872WiliowSt X Danny Davis 7/10/1998 3<br />
ROBBIE MANSFIELD 865 CAMPBELL VILLAGE CT X ZIARA DeBOSE 5/28/2001 1<br />
CARLA GREEN 896 CAMPBELL VILLAGE CT X FRIZZELL DEVERS V 3/5/2001 1<br />
MONIQUE COLE 901 Campbell Village CI X James Evans 6/24/1991 11<br />
EmestClark 928 Willow St X Tyesha Evans 11/23/1990 10<br />
Melica Johnson 900WillowSt X Nashara Fountaine 5/4/2000 2<br />
This is to certify that the infonnation 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 infonnalion 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 Date<br />
Title<br />
Agency<br />
Title<br />
School District<br />
This infonnation 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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