Live Lead Safe Screening Questionnaire

Lead poisoning, even at low levels, can cause learning disabilities, behavioral
issues, or brain damage. Live Lead Safe is a program that seeks to reduce lead paint hazards in homes.

If eligible, the Live Lead Safe program can possibly pay up to 85% of construction costs. Complete this form to find out more.

Applicant Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

How did you hear about the Live Lead Safe program?*

Internet, friend, contractor, etc.

Are you the owner of the property?*

YesNo

Was the property built before 1978?*

YesNo

There are currently: (check all that apply)

Children under the age of 6 living at the propertyChildren under the age of 6 who visit the property for more than 8 hours per weekPregnant women living at the property

We appreciate you looking into the lead safe program. Unfortunately, only the owner of the property can sign up for the Live Lead Safe program.

If you would like us to reach out to your landlord and tell them about the program, you can provide us with contact information below.

We will also email you an occupant packet that explains more about what you can do in your home to be safer.

Property Owner Name

First NameLast Name

Property Owner Phone Number

Please enter a valid phone number.

Property Owner Email

example@example.com

Property Owner Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Stipulations for the owner to be aware of:
1. The owner is responsible for 15% of the overall construction cost.
2. Once the contract is signed for the work to be performed, a lien will be placed on the property for 3 years
3. If the property is under an LLC or Corporation, we will need a copy of the Articles of Organization
4. No outstanding taxes or child support
5. All listed on the deed must sign application and contract

After submitting this form, staff will contact you within 2 business days regarding your interest in the Live Lead Safe program.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What types of concerns do you have about your property?

Please verify that you are human*

Can I participate in the Live Lead Safe Program?