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FederalProperty:<br />
Impact Aid Program Source Check Form Extract<br />
The survey date is December 11,2007.<br />
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 />
Deandre Williams 1229 65th Ave #G X Idaeja Hills-Williams 3114/2002 0<br />
DEANDRE L.WILLIAMS 1229 65TH AVE #G X Teandre Hills-Williams 11/9/1998 4<br />
Rhonda Miller/David Holmes 1260 65TH AVE X Cora Holmes 4/20/1990 12<br />
LAQUANDA GREEN 1305 65TH AVE X Marquise Holmes 9/14/1995 7<br />
MALIKA HEARTFEILD & L10NE 1119 65TH AVE<br />
X Deoote' Holoman 4/511996 6<br />
GENNICE ELLISON 6511 Fenham St #G X Kevin Hope 12120/1992 9<br />
DIEUHUA 113565thAve#H X MiHua 10m1993 9<br />
DUCHUA 1228 65th Ave #C X Phat Hua 5/1711992 10<br />
DIEUHUA 1135 65th Ave #H X Phuong Hua 4/23/1995 7<br />
Latasha Gray 110565thAve#D X Desirae Ibarra 3/4/2000 2<br />
GELENDA BROWN 1341 66th Ave X Juan Ignacio 8/27/1994 8<br />
Shakrita Harris/Cedric Irving 1325 65TH AVE #F X cedric Irving 11/14/1998 3<br />
Shakrita Harris 1325 65th Ave #F X Samuael Irving 9/15/2001 1<br />
KHONSAVANH SOUVANNARA 1246 65TH AVE<br />
This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />
ofthe foregoing sheet(s) is correct for the person listed under Column (1)<br />
on the survey date.<br />
Signature<br />
Title<br />
Date<br />
Agency<br />
X Nate Javius 2110/1995 7<br />
This is to certify that the information shown under columns (4) and (5)<br />
ofthe foregoing sheet(s) Is correclfor the person listed under Column (1)<br />
on the survey date.<br />
Signature<br />
Title<br />
Date<br />
School District<br />
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).<br />
This form must be signed and dated for this school district to receive funds based on this information.
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