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FederalProperty:<br />
Chi Tran<br />
Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
(1) (2) (3) (4) (5) (6) (7) (S)<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 />
Lam Nguyen<br />
CA003003 Address:<br />
1315 65th Ave #0<br />
1253 65th Ave #C<br />
Phuong Thi NguyenlLam Phi Ng 1253 65th Ave #C<br />
LYNNE NICOLS<br />
Jennifer Outley<br />
JUNE ALLISON<br />
Rachel Tijerino<br />
Ikishna Love<br />
April Patrick<br />
Sherry Smith<br />
1340 65th Ave<br />
1219 65th Ave #H<br />
116365THAVE#G<br />
1135 65th Ave<br />
1218 65th Ave #C<br />
6503 Fenham St<br />
1218 65th Ave #H<br />
Adrienne Roy 1258 65th Ave<br />
Malika Heartfield<br />
111965thAve<br />
Hasanni Richard/Monique Bell 6531 Eastlawn st<br />
STARLAMACK<br />
1234 65TH AVE<br />
This Is to certify that the <strong>In</strong>formation 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 />
Date<br />
Agency<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 />
X<br />
X<br />
X<br />
X<br />
X<br />
X<br />
X<br />
Signature<br />
LOCKWOOD GARDENS<br />
Kevin Nguyen 7/20/2000 2<br />
Linda Nguyen 1/512001 1<br />
Lisa Nguyen 11/5/2002 0<br />
Swauva Nichols 1211011991 9<br />
Johnathan Outley 4/26/2002 0<br />
Juvonte Owens 3/16/1991 10<br />
Kendell Owens 1212011999 2<br />
Christopher Patrick 11/30/2002 0<br />
'X Xaire Patrick 6/5/2000 2<br />
X<br />
X<br />
X<br />
X<br />
X<br />
Paula Patterson 12131/1989 12<br />
Oontrel Powell 6/11/2002 0<br />
Jackeerah Ray 10/21/2002 0<br />
Jalyn Richard 8/8/2000 2<br />
Dashawn Rico 8/3/1992 9<br />
This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />
olthe foregoing sheet(s) Is correct for the person listed under Column (1)<br />
on the survey date.<br />
Title<br />
Date<br />
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 <strong>In</strong>formation.
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