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Federal Property:<br />
Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
CA003008D Address: TASSAFARONGA<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 <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 />
Telieia Harris & Antwaan Carroll 8300 G St#A X A1iaja Anderson 4/212001 1<br />
Pamela Hemmingway/Curtis An 945 84th Ave #0 X Arnadi Angelo 4/4/2002 0<br />
Patrice Garrett 938 84TH AVE #F X Armand Belvin 12128/1997 4<br />
Hansberry Regina 935 85th Ave #0 X Alan Brownly 121111995 4<br />
Vanisha Dixon 935 85th Ave #C X Shanika Carter 11/29/1991 10<br />
SOPHALCHAN 8310 G ST#E X David Chan 11/8/1990 12<br />
Angela Chappill 930 84th Ave #E X Danteneh Chappill 8/19/2002 0<br />
TANYA MC CLAIN 930 84TH AVE #A X Derrall Crummie 5/1211989 11<br />
TANYA MC CLAIN 930 84TH AVE #A X Trival Crummie 11/5/1990 11<br />
Sophal Chan 8310 G St#E X Kaylonl Dethvongsa 71712000 2<br />
PEARLIE RUCKER 926 84TH AVE #B X Ricky Flowers 3/15/1995 6<br />
KIMBERLY CHUNN 938 84TH AVE #C X Azuri Freeman 4/1212002 0<br />
CASSANDRA GAAR 918 84TH AVE #C X Adam Gobar 818/1997 5<br />
SHARONDA GREEN 947 84th Ave #C X Emonee Green 7/23/1998 4<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 />
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 />
Signature<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.<br />
Date
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