File In No. tJ ~- 6 Obb

Federal Property:
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
Miracle Turner 877 Campbell Village Ct X Lailani Williams 7/8/2002 0
MICHELE MEADOWS 878 CAMPBELL VILLAGE CT X Mackenzie Williams 121711997 4
Sonya Brtdges 1697 10lh St X Vivicka Williams 2115/2000 2
TALISHIA WARD 914 WILLOW ST X
Date Signature Date
DAVID WOOLRIDGE 6/4/2002 0
Talisha Ward 914 WiliowSl X Mazionna Woolridge 9/19/1993 9
SHEILA PHILLIPS 859 CAMPBELL ST X Lamont Young 10/13/1994 8
Number Students At This Property 48
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.
Signature
Title
Agency
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.
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.