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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 (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian <strong>In</strong> Date of Grade<br />
If applicable) lived on worked on Column (1) Birth<br />
Rachel Tijerina 1135 65th Ave #G X<br />
ERIC JOHNSON SR. 1103 65th Ave X<br />
Chartotte Lynn 1254 65th Ave X<br />
ERIC/NADINE JOHNSON<br />
1103 65th Ave #C<br />
PATRICIA JOHNSON 1222 65TH AVE X<br />
Nadine Allen/Eric Johnson 110365thAve#C X<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 />
X<br />
AU9us<strong>tJ</strong>ohnson 5/24/1997 5<br />
Eric Johnson 217/1993 9<br />
Jahns Johnson 2115/2000 2<br />
Krystal Johnson 10/13/1991 9<br />
Love Johnson 8/29/1991 9<br />
Nadine Johnson 11/27/1995 6<br />
MONIQUE HUNTER 1201 65TH AVE #F X Jae'La Jones 11/10/1994 8<br />
FRANCESCA DAVIS 1101 65th Ave #G X<br />
Stephanie Pierce 1257 66th Ave X<br />
Stephanie Pierce & Patrick Kelly 1257 66th Ave<br />
Jacqueline DorseyNance Stewe 1124 65th Ave #0<br />
Marcia Hollie 1228 65th Ave X<br />
CATRINASIMS<br />
1225 66th Ave<br />
APRIL LEWIS 1332 66TH AVE X<br />
This Is to certify that the <strong>In</strong>fonnatlon shown under columns (4) and (5)<br />
of the fore90in9 sheet(s) Is correct for the person listed under Column (1)<br />
on the survey date.<br />
Signature Date Signature<br />
Title<br />
Agency<br />
Sidney Jones 11/15/1990 10<br />
Ashantt Kelly 3/21/2001 1<br />
X ImanJKelly 8/25/1998 3<br />
X<br />
X<br />
Ja'Kel Keys 9/23/2001 1<br />
Gerrah Lampkin 3/11/1994 8<br />
Deijunae Lebrane 8/16/1994 8<br />
Mizahni Lewis 4/1711999 3<br />
This Is to certify that the infonnatlon shown under columns (4) and (5)<br />
olthe foregoing sheet(s) Is correcllor the person listed under Column (1)<br />
on the survey date.<br />
Title<br />
Date<br />
School District<br />
This <strong>In</strong>fonnation 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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