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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 (<strong>In</strong>cluding rank, in 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 />
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 />
SAMUELA BLACKSHER 1103 65th Ave #A X Andre Ridge 2113/1992 9<br />
SAMUELA JEAN BLACKSHER 110365thAve#A X Semaj Ridge 6/10/1993 8<br />
LATRINA RIVERAIALQUILINO 6507 EASTLAWN ST X BRIONA RIVERA 6/8/2001 1<br />
REMOUS TOOMBS 113565thAve#A X Jon Rodgers 3/9/1992 10<br />
CLAUDIA RODRIGUEZ 1219 65th Ave #D X Angelina Rodriguez 7/24/1996 6<br />
Claudia Mendez 1219 65th Ave #D X Pedro Rodriguez 11/17/1992 10<br />
Angelina Romero 1109 65th Ave X Ana Romero 10/10/1995 7<br />
Angelina Romero 1109 65TH AVE X EDGAR ROMERO 1/29/2002 0<br />
Angelina Romero 1109 65th Ave X Eduardo Romero 212612000 2<br />
ANGELINA ROMERO 1109 65th ave X Jesus Romero-Gil 5/28/1994 8<br />
June Allison/Prophet Sar 116365thAve#G X Jakil Sarhim 6/30/1997 5<br />
Ashaki Thomas 1262 65th Ave #G X Akashi Soott 1/6/1993 9<br />
ELEANOR EDMONDS 6503 Fenham St #A X Jonathan Soott 12126/1991 9<br />
CHRISTINA SHAVERS 1333 66TH AVE X Darien Sensabaugh 8/18/1994 8<br />
This is to certify that the information shown under columns (4) and (5) This is to certify that the information shown under columns (4) and (5)<br />
of the foregoing sheet(s) Is correct for the person listed under Column (1) ofthe foregoing sheet(s) is correct for the person listed under Column (1)<br />
on the survey date. on the survey date.<br />
Signature<br />
Date Signature Date<br />
Title Agency Title<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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