File In No. tJ ~- 6 Obb

Federal Property:
Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
CA003008D Address:
(1) (2) (3) (4) (5) (6) (7) (8)
Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living With Pupil's Pupil's
Name Address (Including rank, In Column (1) In Column (1) Parent/Guardian In Date of Grade
If applicable) lived on worked on Column (1) Birth
or above property above property
Foreign Military as of as of
Government survey date survey date
Fatima Aikens 8300 G St#B
EVELYN STEPHENS 8300 GST#B
Delishia Wills 938 84TH Ave #A
SHARON WELCH 915 84th Ave #a
Aisha Nalls 938 84TH AVE #D
VERNETTA WOODS 938 84TH AVE #E
Number Students At This Property
This Is to certify that the Information shown under columns (4) and (5)
of the foregoing sheet(s) Is correct for the parson listed under Column (1)
on the survey date.
Signature
Title
Date
Agency
48
YES I NO YES I NO
TASSAFARONGA
X Dajah White 5/14/2001
X Mikiesha Williams 2/16/1994 7
X TajaeWilis 5/2/1996 5
X Cortez Wilson 9/12/1995 7
X Mack Woodfox 12/25/1997 4
X Zaria Woods 6/5/1998 4
This is to certify that the Information shown under columns (4) and (5)
of the foregoing sheet(s) Is correct for the person listed under Column (1)
on the survey date.
Signature
Title
Date
School District
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).
This form must be signed and dated for this school district to receive funds based on this information.