Lead Hazard Control Program Consultation Form

Lead Hazard Control Program Consultation Form

Community Development 815 Washington St Room 2-54 Reading, PA 19601 610-655-6460 / 610-655-6466 - LeadProgram@readingpa.gov
Name *
Date *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number *
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Gender: *
Residence Type: *

Homeowner Rental
Head of Household: *

Yes No
Are you a single parent? *

Yes No
Total # of members in your family: *
Total annual income of your family: *
Minors under the age of 6 in the family? If yes, please include age: *
Is any woman in the household pregnant at this moment? *

Yes No

Race/Ethnicity of Household: *

	Total # of Race Response:	Total # of Hispanic or Latino Reponses:
American Indian or Alaska:
Asian:
Black or African American:
Native Hawaiian or other Pacific Islander:
White:
Amiercan Indian of Alaska Native AND White:
Asian AND White:
Black or African American AND White:
Other multiple race combinations greater than 1%:
Balance of individuals reporting more than one race:

Summary of situation in household: *
How did you hear about us? *
Documents that we need to continue the process:

1. Copy of valid state ID for all adults in household.

2. Copy of social security cards for all members of household.

3. Copy of birth certificates for all minors in household.

4. Copy of lease - If rental.

5. Doctor's certification and labs.

6. Income verification:

·         Recent bank statement - Checking and/or Savings

·         Last year tax return

·         Pay stubs for all persons over 18 in the household

·         Current social security benefits statements, SSI and/or welfare benefits

·         Current unemployment benefits statements

·         Current child support statements

·         All other income
I hereby certify that the information provided on this form is true and accurate.
Applicant's Signature *

Clear
Should be Empty: