Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
Federal Property: CA003018 Address: 3532 PIERSON ST<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, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />
If applicable) lived on worked on Column (1) Birth<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 />
Latanya Douglas 3532 Pierson St #4 X Deandre Douglas-Richards 12130/1998 3<br />
Terry, Lakeiva 3532 Pierson St #5 X Anlwan Jackson 5/15/2001 0<br />
Suzanna Pineda 3532 Pierson St #5 X Khristopher Martinez 6/8/1998 4<br />
lakeiva Terry 3532 Pierson St #5 X Wilneisha Patterson 8/24/1999 2<br />
Terry, LakeivaiRoyal,Keon 3532 Pierson St #5 X Keondra Royal 10/26/2002 0<br />
LATANYA DOUGLAS 3532 PiERSON ST #4 X Tremaine Wheaton 7/30/1991 11<br />
LATANYA DOUGLAS 3532 PIERSON ST #4 X Trevonn Williams 4/9/1994 8<br />
Number Students At This Property 7<br />
This Is to certify that the information 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 />
This is to. certify that the information shown under columns (4) and (5)<br />
olthe foregoing sheet(s) is correct for the person listed under Column (1)<br />
on the survey date.<br />
Signature Date Signature Date<br />
Title Agency TItle 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 <strong>In</strong>formation.