Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Lead Safe Lansing Application Request

  1. Property address

  2. Complete the following information if the property is a Single Family Home

  3. Number of bedrooms

  4. Number of adults

  5. Number of children

  6. Number of children under 6 years old

  7. Tenants name

  8. Tenants gross income

  9. Complete the following information if the property is a Multi-Family Home

  10. Number of bedrooms

  11. Number of adults

  12. Number of children

  13. Number of children under 6 years old

  14. Tenants name

  15. Tenants gross income

  16. Number of bedrooms

  17. Number of adults

  18. Number of children

  19. Number of children under 6 years old

  20. Tenants name

  21. Tenants gross income

  22. Number of bedrooms

  23. Number of adults

  24. Number of children

  25. Number of children under 6 years old

  26. Tenants name

  27. Tenants gross income

  28. Number of bedrooms

  29. Number of adults

  30. Number of children

  31. Number of children under 6 years old

  32. Tenants name

  33. Tenants gross income

  34. Property owner's name

  35. Address

  36. City, State, Zip Code

  37. Telephone Number

  38. Alternate telephone number

  39. Email address

  40. PRIORITY

    Children under age 6 with identified EBLL (over 5 ug/d)

  41. Pre-1940 house with child under 3 resides

  42. Previous poisoning at this house, currently occupied by child under 3

  43. House where child has been poisoned by lead previously

  44. Pre-1978 house where child under 6 years OR a pregnant woman resides

  45. Leave This Blank: