SCACAP Housing Rehab Pre-Application

Income Information
Are you receiving other sources of income such as alimony, child support, social security, etc?

YesNo
Please list those other sources below:
Estimated household income
Please click the link below for the median income guide:

Income Limits Documentation System

(Adults) 2 forms of ID Verification (A Valid, Government-Issued Photo I.D. for the Applicant)

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Proof of Ownership or Lease (copy of the deed, property tax bill, etc.)

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Healthy Homes Assessment Checklist
Date of Assessment

MonthDayYear
Date
Inspector Name*
Property Address*
Property Owner Name*
Purpose: To address Healthy Homes hazards in properties receiving Lead Based Paint Hazard Control funding from the U.S. Department of Housing and Urban Development Office of Lead Hazard Control and Healthy Homes. Only identified Healthy Homes Hazards are eligible for funding.

Healthy Homes Supplement funding will be used in the following order as funding allows:

a. Non-lead based paint housing conditions that are an imminent threat to an occupant's health or safety who is disabled, under the age of 18 or over the age of 55.

b. Non-lead based paint housing conditions that are an imminent threat to any occupant's health or safety.

C.Correctable housing conditions that will allow the residents to have a better and healthier quality of life.

The 29 Housing Hazards that were inspected are in the following chart:

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