LEAD HAZARD ABATEMENT PROGRAM

LEAD HAZARD ABATEMENT PROGRAM
Guidelines for Completing the Lead Hazard Abatement Program Application

For timely and accurate processing, please follow all of the steps listed below. If you need assistance to complete this application, please call (334) 327-1710 or (334) 327-1609

1) Answer all questions on the application accurately.

2) Place your signature in the appropriate spaces. (If you are a renter, you will need to ask your landlord to sign this form prior to submission. Staff members at the City of Selma Planning & Development/Lead Safe Selma can provide program information to landlords upon request

3) Turn in copies of all required documents. If you do not have access to a photo copier, please deliver your application in person at the address below so your documents can be copied and immediately returned to you.
REQUIRED DOCUMENTS

(to be submitted with application)

□ IRS tax forms or Form W-2 (wage and tax statement)

□ Additional form of income verification for each household member, all that apply to your household:

□ Paystubs for the most recent 3 months

□ Social Security earnings or Supplemental Security Income statement□ Disability or Worker's Compensation

□ Child Support or Alimony

□ Other annuity or retirement income statements

□ Bank Statements (last 3 months)

□ If there are adults living in the household that are not employed, a notarized "verification of no income" form (included on lastpage of the application)

□ If a homeowner, proof of ownership in property (Warranty Deed, Quitclaim Deed, or Title Opinion)

□ Driver's license or identification card for applicant

□ Social Security Card for applicant

□ Blood Lead Level Test Results for children under age 6 or pregnant women occupying the home (optional)

□ Proof of Homeowners Insurance (Declarations Pages from Insurance Company
Questions, Forms & Required Documents can be returned to any of the following locations:

City of Selma 222 Broad Street Selma, AL 36701

Lead Hazard Abatement Program City of Selma 222 Broad Street Selma, AL 36701

(334) 327 1710 leadprograms@selma-al.gov or (334) 327-1609 leadtech@selma-al.gov

Version 2.0 (Updated 5/12/2022)
Version 2.0 (Updated 5/12/2022)

Household Information

I hereby declare the following person(s) live within my household for more than 51% of the time. Therefore, this person or persons should be included in my household number and their income should be calculated into my household income.

	Full Name	Birthdate	Age	Relationship to Applicant	Employed? Y/N	Full Time Student?Y/N
1
2
3
4
5

Children Under 6 Who Frequently Visit the Home (Program Requirement if a child under 6 does not live in home)

If a pregnant woman and/or child under the age of 6 frequently visits your home--(defined as 3 hours a day on 2 separate days a week and/or a total of 60 hours per year) list them in the section below. (Information reported in this section will not impact status of household size)

	First and Last Name of Child	Birthdate	Age	Relationship to Applicant	Describe when and how long child visits your home.
1
2
3
4
5
6

List employment information for all age 18 or over in household who work. If a household member has multiple jobs, all employment should be reported. By signing this application, you are authorizing City of Selma Planning & Development Department/Lead Safe Selma to contact your employer for verification of your employment and reported income.
Household Employment Information (Please complete all fields)
1. Household Member Name
Hire Date

MonthDayYear
Date
Hourly Wage
Hours worked per week
Supervisor Name
How many hours of overtime do you usually acquire per pay period?
Average Monthly Income
Email
example@example.com
Rate of Pay
Name and Address of Employer
Business Phone
2. Household Member Name
Hire Date

MonthDayYear
Date
Hourly Wage
Hours worked per week
How many hours of overtime do you usually acquire per pay period
Average Monthly Income
Supervisor Name
Email
example@example.com
Rate of Pay
Name and Address of Employer
Business Phone

3. Household Member Name
Hire Date

MonthDayYear
Date
Hourly Wage
Hours worked per Week
Supervisor Name
How many hours of overtime do you usually acquire per pay period
Average Monthly Income
Email
example@example.com
Rate of Pay
Name and Address of Employer
Business Phone
4. Household Member Name
Hire Date

MonthDayYear
Date
Hourly Wage
Hours worked per Week
How many hours of overtime do you usually acquire per pay period
Average Monthly Income
Rate of Pay
Supervisor Name
Email
example@example.com
Name and Address of Employer
Business Phone

STATEMENT ON ELIGIBILITY AND PRIORITIZATION

Please initial by each statement as applicable.

FOR OCCUPANTS OF THE PROPERTY (renters or homeowners)
I understand that this program suggests that children under 6 years old be tested for blood lead poisoning before and after lead reduction work is done on the home, and that I will be required to submit documentation from a medical service provider that states the blood lead level of each child occupying the home. I understand that this information will be treated as confidential

Clear
I understand that program administrators may need confirmation of blood lead testing results, and I authorize the City of Selma to obtain blood lead laboratory results for any children under the age of 6 of the home that received testing and share these results confidentially with authorized program representatives including the Alabama Department of Public Health.

Clear
I understand that homes with children under 6 years of age or pregnant women with an Elevated Blood Lead Level will be given higher priority for program enrollment and scheduling of abatement activities.

Clear
I understand that all occupants of the property may be required to temporarily relocate from the property while lead abatement activities are ongoing at the expense of the Program.

Clear
I understand that program income eligibility for renters is 50 to 80 percent of Selma's area median income, and for homeowners is 80 percent of Selma's area median income, and I must provide approved forms of income documentation to demonstrate eligibility.

Clear
I understand that the City of Selma will review this application for eligibility, but that none of the information included in this application or its supporting documentation will be shared with any other party unless the applicant has been notified of the Privacy Practices of the agencies and given consent in writing to do SO.

Clear
FOR OWNERS OF THE PROPERTY (homeowners or landlords)
I understand that Lead Safe Housing Registry will be used to track lead abatement and clearance activities of this and future lead programs in Selma for all properties improved using public funding.

Clear
I understand that I will be required to sign an agreement with the City of Selma in order to participate in the Lead Hazard Abatement Program.

Clear
(FOR LANDLORDS ONLY) By participating in the program, I agree to market the property to low income families with children under age 6 or pregnant women for a period of 3 years, and submit income verification documents to the City of Selma during that period.

Clear

By signing below, I (we) certify that the income and household composition is correct to the best of my (our) knowledge and belief. I understand that by providing false information on income and household size, it will constitute a fraudulent action and my (our) application may be denied.
OwnerLandlord Name Print
Date

MonthDayYear
Date
OwnerLandlord Signature

Clear
Date

MonthDayYear
Date
Tenant Name Print
Date

MonthDayYear
Date
Tenant Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

LEAD HAZARD ABATEMENT PROGRAM

Property Information

Household Information

Household Employment Information (Please complete all fields)