File In No. tJ ~- 6 Obb

Federal Property:
Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
CA003013 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
EUGENIA JACKSON 727 37TH ST #6
EUGENIA JACKSON 727 37th St #6
LATRENDA SMITH 522 32ND ST #4
LATRICIA KING 727 37TH ST #5
Eugenia Jackson 727 37TH ST #6
Jackson ,Eugenia 727 37TH ST #6
latrice Johnson 727 37th St #4
Number Students At This Property
This is to certify that the information shown under columns (4) and (5)
ofthe foregoing sheet(s) Is correct for the person listed under Column (1)
on the survey date.
Signature
Title
Date
Agency
7
72737TH ST
YES I NO YES I NO
X Amika Barriga 11113/1989 11
X Arnisha Barriga 11113/1989 11
X Malika Cade 3/1011991 10
X Devin Hooten 1/1911990 11
X Harry lawrence 211611998 4
X Horatio Lawrence 11117/2001 1
X Christian Rhodes 11/211996 4
This Is to certify that the Information shown under columns (4) and (5)
ofthe 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.