File In No. tJ ~- 6 Obb

Impact Aid Program Source Check Form Extract
The survey date is December 11, 2007.
FederalProperty: CA003019 Address: 2558 35TH AVE
(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
YES I NO YES I NO
Valeria Parker 2558 35th Ave #10 X Adam Parker 6/30/1993 9
VALERIE PARKER 2558 35TH AVE #10 X Katelyn Parker 2/7/1991 10
Sonltha Sil/Mike En 2558 35th AVe #11 X Lana Res 1211612001 0
Sokun Sit 2558 35th ave #11 X Lily Res 8/27/2000 2
MUEYCHAO 2558 35TH AVE #8 X Franklin Saephanh 11/7/1992 10
Valerie Parker 2558 35th Ave #10 X Makaylia Smith 5/23/2001 1
Sharena N. Thomas 2558 35th Ave #7 X Augenique Thomas 12117/1994 7
Number Students At This Property 21
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.
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 Date Signature
Date
Title Agency Title School District
this Information is the basis for payment to this school district oUederal 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.