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Signature<br />
Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
FederalProperty: CA003016 Address: 1248 E 34TH ST<br />
(i) (2) (3) (4) (5) (6) (7) (S)<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, <strong>In</strong> Column (i) <strong>In</strong> Column (i) Parent/Guardian <strong>In</strong> Date of Grade<br />
if applicable) lived on worked on Column (i) Birth<br />
or above properly above properly<br />
Foreign Military as of as of<br />
Government survey date survey date<br />
YES I NO YES T NO<br />
ALICE BYERS-BIGGINS 1248 E 34th St#101 x A10nteBiggins 5/20/1996 6<br />
Lisa Pace 2451 RENWICK ST #104 X Freddie Dunbar 1/7/1992 9<br />
Edana Evans 554 37TH ST #202 X Joshua Evans 11/12/1998 4<br />
Kimberly Keesee/Belty Scotl/An 2451 Renwick Sl #103 X Kris Fletcher 7/29/2001 1<br />
APRIL FORD 1246 E 34TH ST #302 X Timothy Ford 6/6/1997 5<br />
Joh/Ashanti Fullard 2451 Renwick SI#103 X Jalen Fullard 3/1011999 3<br />
FAYE WALKER 1248 E 34TH ST #301 X Tommy Gates 2/14/1993 9<br />
FAYE L. WALKER 1248 E 34TH ST #301 X TomyGates 2/14/1993 9<br />
Teresa Jackson 554 37TH ST #303 X Roderick Godfrey 1/15/1997 4<br />
EDANA EVANS 554 37TH ST #202 X Antonio Harris 8/611994 8<br />
Harvey, Olivia 554 37th St #302 X Andre Harvey 5/4/1997 5<br />
Denise Harvey 554 37th St #302 X Angelina Harvey-Mendez 11/8/2001 1<br />
WILLIE & DELORES HILL 2529 9TH AVE #103 X AlaniHiII 5/15/1996 6<br />
DELORES HILL 2529 9TH AVE #103 X Jakari Hill 12/15/1998 3<br />
This is to certify that the <strong>In</strong>fonmation shown under columns (4) and (5)<br />
olthe foregoing sheet(s) is correct for the person listed under Column (1)<br />
This is to certify that the infonmatlon 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 />
on the survey date.<br />
Title<br />
Date<br />
Agency<br />
Signature<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 <strong>In</strong>formation. •
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