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Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
Federal Property: CAO03003 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, in Column (1) <strong>In</strong> Coiumn (1) Parent/Guardian <strong>In</strong> 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 />
YAN LI 1253 65th Ave #D X Mei Yun Li 4/15/1994 8<br />
YANLI 1253 65th Ave #D X Qlyun LI 4/22/1996 6<br />
STARLAMACK 1234 65TH AVE X Charles Mack 1/15/1999 3<br />
STARLAMACK 1234 65TH AVE X Devaunte Mack 10/1611993 8<br />
DERRICK MAPP 1262 65TH AVE #C X Onyx Mapp-Childs 3/2/1993 9<br />
Drusilla Zeno 1315 65th Ave #H X Dajohn McConnick 71712000 2<br />
Marcilla labice Marable 6506 Fenham St X Tzion Mcelroy 6/23/2001<br />
SAVORNMEY 1228 65TH AVE #F X Sroeun Jr Mey 6/27/1995 7<br />
KIM KING 1334 65TH AVE X Kendale D'Ang Molden 12/31/1995 6<br />
QUINTINA BONDS 1101 65TH AVE #B X Lou-Zhane Montgomery 7/13/2001 1<br />
KIML. WALLS 1219 65TH AVE #B X Disserae Moore 5/20/1990 12<br />
Dywan Nelson 1229 65th Ave #B X Devante Nelson 111711996 5<br />
Lanelta Figg 1163 65TH AVE #C X Quintin Nelson 5/17/1997 5<br />
Shamika Newman 6520 Eastlawn St X Tayshawn Newman 10/20/2001 1<br />
This Is to certify that the <strong>In</strong>formetlon shown under columns (4) and (5) This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />
ofthe foregoing sheet(s) Is correctfor the person listed under Column (1) of the 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<br />
Agency Title School District<br />
This <strong>In</strong>formation 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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