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Signature<br />
Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
Federal Property: CA003019 Address: 2558 35TH AVE<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 <strong>In</strong> 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 />
VALERIE PARKER 2558 35TH AVE #10 X Markell Brooks 5/24/1998 4<br />
SharenaiDawa Curley 2558 35th Ave #7 X Dante Curley 9/15/1999 2<br />
JININAKEYS 2558 35TH AVE #5 X Shanlna Hill 6/16/1990 11<br />
Samphors Wok 2558 35th Ave #5 X Sovann Kay Jr 11/11/2001 1<br />
JININAKEYS 2558 35TH AVE #5 X Akeena Keys 10/14/1993 9<br />
LEWAN YANG 2558 35th Ave #9 X Dorothy Le 11/15/1996 5<br />
Sarita Panngasiri 2558 35th Ave #3 X Thaila Mannorind 1/19/2000 2<br />
Ardrea Perry 2558 35th Ave #4 X De Vante Monroe 2/24/1994 7<br />
VON MORRIS 2558 35TH AVE #4 X Akirra Morris 10/12/1996 5<br />
Ardrea Perry 2558 35th Ave #4 X Alexuis Morris 9/17/1995 6<br />
Von Douglas Manis/Andrea Perr 2558 35th Ave #4 X Savonte Morris 5/12/2002 0<br />
VON MORRIS 2558 35TH AVE #4 X Von Morris Jr 3/5/1997 4<br />
SAMPHORS NOK 2558 35TH AVE #6 X Arna <strong>No</strong>k 612711990 11<br />
KHAMKHEUANG PANNGASIRI 2558 35th ave #3 X Sharleen Panngasiri 7/25/1990 11<br />
This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5) This Is to certify that the <strong>In</strong>formation shown under columns (4) and (5)<br />
of the foregoing sheet(s) Is correct for the person listed under Column (1) 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 />
Date Signature<br />
Title Agency Title<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.<br />
Date
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