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Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
FederalProperty: CA003003 Address: LOCKWOOD GARDENS<br />
(1) (2) (3) (4) (5) (6) (7) (8)<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 />
PATRICIA JOHNSON 1363 66th Ave X Mark Collins 12123/1990 10<br />
Melita Jenkins 1149 66th Ave X Elena Cook 6/28/2002 0<br />
Rachel Hicks 1320 65th Ave X Selena Cordaway 11/27/1998 3<br />
Miranda Achie 1205 65th Ave X Keyana Crisp 12110/1992 9<br />
TAMMY WILLIAMS 1253 65TH AVE #H X Hassan Darrah 12130/1992 9<br />
Mack, StartaiDennis, Kelvin 1234 65th Ave X Kelviauna Dennis 8/1/2002 0<br />
MICHELLE CARTHON & VELV 1316 65TH AVE X Denne' Dickson 1/13/1996 6<br />
MICHELLE CARTHON 1316 65th Ave X Dontae Dickson 9/3/2001 1<br />
CARMEN L.MILLER 1136 65th Ave #0 X Iyala Edmond 8/25/1999 2<br />
GLORIA RICHARD 1252 65th Ave X Omari Embrey 7/30/1998 3<br />
Tomisha Wade 1110 65th AVE X Jordan Emmanuel 6/8/2002 0<br />
KESHIA EVANS 1125 65th Ave X Da'Janae Evans 4/21/1992 9<br />
KEISHA EVANS/ALFREDIA 1125 65th Ave X Keshla Evans 4/21/1992 9<br />
Shelonda Evans 1356 65th Ave X Vaughn Evans-Chandler 8/19/1998 4<br />
This is to certify that the infonnation shown under columns (4) and (5) This is to certify that the infonnatlon shown under columns (4) and (5)<br />
of the foregoing sheet(s) is correct for the person listed under Column (1) olthe foregoing sheet(s) is correct for the person listed under Column (1)<br />
on the survey date. on the survey date.<br />
Signature Date Signature Date<br />
Title Agency Title School District<br />
This <strong>In</strong>tonnation 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 <strong>In</strong>formation.
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