You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
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 (including rank, in Column (1) in Coiumn (1) Parent/Guardian <strong>In</strong> Date of Grade<br />
if applicable) lived on worked on Column (1) Birth<br />
FATINMAAIKENS<br />
PEARLEAN LEGGINS/Gwen Hi<br />
ANDREA HAYWOOD<br />
8300 G St#6<br />
915 84TH AVE #6<br />
926 84TH AVE #E<br />
VIRGILIA GAYLORD & JAMES 8300G ST#E<br />
REGINNSHARN1CE<br />
935 85th Ave #0<br />
Soeub Say 926 84TH AVE #A X<br />
TANYA MCCLAIN MICHAEL<br />
Shalena D. Edwards<br />
VANISHA A. DIXON<br />
VANISHA DIXON<br />
DELISH1AVALLIER<br />
SONYA VERDINE<br />
VICKIE GOINS<br />
AISHANALLS<br />
930 84TH AVE #A<br />
941 84th Ave<br />
935 85TH AVE #C<br />
935 85TH AVE #C<br />
938 84TH AVE #A<br />
935 85TH AVE #E<br />
8300G ST#E<br />
938 84TH AVE #0<br />
This Is to certify that the information shown under columns (4) and (5)<br />
ofthe foregoing sheet(s) is correctfor 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 />
X<br />
X<br />
X<br />
X<br />
X<br />
Signature<br />
KAMAR NELSON 10/25/2002 0<br />
Lakisha Peoples 5/6/1993 8<br />
Kenneth Perry 6/21/1994 8<br />
Jessica Posey 11/15/1993 8<br />
Anthony Snead 10/1411993 8<br />
Amanda So 11/28/2000 2<br />
De'Jomae Thomas 5/22/1995 7<br />
Tyrone Thompson Jr 8/16/1999 3<br />
Casey Tumer 10/11/1994 6<br />
Sir William Tumer 10/29/1997 4<br />
Chlishay Vallier 9/2/1994 8<br />
Sultanah Waqia 111712000 2<br />
Joshua Wheelock 1/10/1992 10<br />
Ayana While 6/12/1996 6<br />
This is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />
ofthe 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 <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.
Change language