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*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Gender:*
HomeownerRental
YesNo
YesNo
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:*
YesNo

Race/Ethnicity of Household:*

Rows	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 birth certificates for all minors in household.

3. Copy of lease - If rental.

4. Doctor's certification and labs.

5. 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*
Should be Empty: