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Federal Properly:<br />
Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
CA003008D Address:<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 (including rank, in Column (1) in Column (1) Parent/Guardian in Date of Grade<br />
if applicable) lived on worked on Column (1) Birth<br />
DELISHIA WILLS 938 84TH AVE #A X<br />
SHARON WELCH<br />
ROTRINDA WALLS<br />
915 84th Ave #A<br />
947 84th Ave #A<br />
RyniquekaiJefferey Hodge 917 84th Ave #E X<br />
ARTIS JOHNSON & LATONYA 917 84TH AVE #D X<br />
Janelle Murphy<br />
ArIIs Johnson/Elizabeth Allen<br />
926 84th Ave #c<br />
917 84th Ave #D<br />
DARRICK KENNEDY 918 84TH AVE #D X<br />
Lanesa Franklin 945 84th Ave #E X<br />
Franklin, Lanesa 945 84th Ave #E<br />
CASSAUNDRA GAAR 918 84TH AVE #C X<br />
EVELYN STEPHENS<br />
YOEUNGMEAS<br />
YOEUNG MEAS<br />
8300G ST#B<br />
8310 G ST#A<br />
8310 G ST#A<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 />
TASSAFARONGA<br />
Akaysha Grogans 11/6/1991 10<br />
Ameriah Hayes 5/15/1992 10<br />
Kanesha Herron 5/17/1991 10<br />
Jarrett Hodge 81812000 2<br />
Artisha Johnson 4/1311995 7<br />
Farrarri Johnson 3/17/2000 2<br />
Mercedes Johnson 10/1211992 9<br />
Rakheem Kennedy 4/1911996 6<br />
Dannisha Lacey 3/2211996 6<br />
Davon Lacey 6/20/1997 5<br />
Ashley Lon9 11/311991 10<br />
Fredniesha Me Raven 1/211991 11<br />
RadyMeas 2124/1990 11<br />
Sokphany Meas 212211992 10<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 />
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.
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