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FederalProperty:<br />
Impact Aid Program Source Check Form Extract<br />
The survey date is December 11,2007.<br />
CA003008A Address: 1110 64TH AVE<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 />
or above property above property<br />
Foreign Military as of as of<br />
Government survey date survey date<br />
STEPHANIE WILLIAMSON 6403 FENHAM ST #59<br />
Latonia Thomas<br />
6403 Fenham St #26<br />
Number Students At This Properly 2<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 Agency<br />
Date Signature<br />
YES I NO YES I NO<br />
x<br />
x<br />
Kyndal Lakey<br />
Jeanna Thomas<br />
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)<br />
on the survey date.<br />
Title<br />
Date<br />
School District<br />
This information 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.<br />
11/1/1993<br />
3/9/1994<br />
8<br />
7
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