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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 in Date of Grade<br />
if applicable) lived on worked on Column (1) Birth<br />
Monica Rice-Walker<br />
Monica Rice-Walker<br />
1229 65th Ave #D<br />
1229 65th Ave #D<br />
Jameelah Smith 1201 65th Ave #D X<br />
VELMA MARIE RICHARDSON 1306 65TH AVE X<br />
Marcia Hollie<br />
1228 65th ave<br />
LISA BRADY 1252 65TH AVE #D X<br />
VIRGINIA ALLEN 1157 65TH AVE X<br />
ROCHELL JAMERSON<br />
1252 65th Ave #A<br />
VIGINIA ALLEN/JOSEPH WILLI 1157 65th Ave<br />
VIRGINIA ALLEN<br />
Joyce Leeks<br />
Quintina Bonds' Kelly<br />
1157 65th Ave<br />
1263 65th Ave #C<br />
1101 65th Ave<br />
CARMEN MILLER 1136 65th Ave #D X<br />
Tywana Titus/Mario Woodard 6503 Fenham St #F X<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 />
Benicia Walker 10/10/2000 1<br />
Bennie Walker 12115/1998 4<br />
Jawon Wallace 10/1212000 2<br />
Tameisha Ware 6/15/1993 8<br />
Shemirah Waters 3/6/2001 0<br />
Michelle Watts 9/9/1995 7<br />
Jonetta Williams 6/11/1995 7<br />
Klanie Williams 5/25/1999 3<br />
La Gina Williams 4/6/1992 10<br />
Lajoyce WIlliams 3/8/1991 11<br />
Randy Williams 12126/1993 8<br />
Shonesha Wilson 8129/2000 2<br />
T'evinWilson 11/16/1991 10<br />
Daven Woodard 216/2002 0<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 />
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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