File In No. tJ ~- 6 Obb

FederalProperty:
Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
CA003002 Address: CAMPBELL VILLAGE
(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
Shwana Ammons 860WillowSt X Diamond Myles 1216/1999 2
STEPHANIE THOMAS 871 Campbell SI X Leilani Noel 4/6/2001 1
SHERRY SIMS 901 CAMPBELL ST X Marcus O'Neal 9/5/1999 3
HAZEL DIXON 915 campbell Village Ct X Norisha Price 2118/1999 3
POEV THOU & SATH PROM 1667 10TH ST #E X Shirley Prom 9/1211995 7
Wanda Reedffreya Reed 895 campbell SI X Cuevona Reed 4/2212001 1
NAKIMA WALKER 915 CAMPBELL ST X Kehinde Riley 1/211996 6
THELMA ROSS 824 WILLOW ST #B X Sherry Ross 7/13/1999 3
LA TREASHA MCCOY 884 Willow SI X Malik Salam 3/5/1994 9
RANDY HARVEY 1692 8TH ST X Kilomokie Stewart 8117/1998 3
JANICE C. TOWNSEND 884 Campbell Village Cl X AmaniTownsend 9/14/1999 2
OULIMATASY 879 campbell SI X Maguell Wade 7/27/1995 5
Michele Meadows 878 Campbell Village Ct X Andrew Williams 6/26/1989 12
KELLYE MOORE 865 Campbell SI X Kenisha Williams 7/11/1990 12
This Is to certify that the Information shown under columns (4) and (5)
olthe foregoing sheet(s) Is correcllor the person listed under Column (1)
on the survey date.
Signature
Title
Date
Agency
This Is to certify that the Information shown under columns (4) and (S)
of the foregoing sheet(s) Is correct for the person listed under Column (1)
on the survey date.
Signature
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.