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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 />
christina marie shavers 1333 66th Ave X D'ovyon Figg 8/2212001 1<br />
Monique Bell 6531 EasUawnSI X Jason Fluker 1110/1992 10<br />
GLENN FULLER 1234 65th Ave X De'Janee Kiar Fuller 10/16/1989 9<br />
Patricia Gates 1262 65th Ave #B X Jerrell Gates 10/28/1999 2<br />
Dansheeka Glaser 1107 65th Ave X Jayla Glaser 8/3/2002 0<br />
Ruby Habeebullah 1325 65th Ave X Alonzo Grays 5/30/2001 1<br />
LAYLAGREEN 1225 66th Ave X Rachel Green 5/24/1991 11<br />
SHELIA L. SMITH 1201 65TH AVE #C X Stardazia Hailey 4/7/1999 3<br />
VALERIE MILTON 1263 65TH AVE X Latifa Hairston 5/2911990 11<br />
AUTONYALEE 1163 65TH AVE #A X Tiyanna Harris 7/1611992 9<br />
VELMA MCDANIEL & NOBLE H 6503 FENHAM ST #H X <strong>No</strong>ble Harris IV 6/26/1994 8<br />
MALIKAIMARION JACKSON 1119 65th Ave X Javaughnie Heartfield 7/13/1992 10<br />
CYNTHIA WILLIAMS 1229 65TH AVE #H X Ashley Hightower 8111/1994 7<br />
DONALDNELMA RICHARDSO 1306 65TH AVE X ShanUerraHill 12131/1995 6<br />
This is to certify that the <strong>In</strong>fonnation 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 />
Signature<br />
Title<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 />
Date Signature Date<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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