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Lead Safe Lansing Application Request

  2. Property address

  5. Property is:

  6. Mortgage (yes / no)

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

  10. Number of bedrooms

  11. Number of adults

  12. Number of children

  13. Number of children under 6 years old

  15. Tenants name

  16. Tenants gross income

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

  20. Number of bedrooms

  21. Number of adults

  22. Number of children

  23. Number of children under 6 years old

  25. Tenants name

  26. Tenants gross income

  28. Number of bedrooms

  29. Number of adults

  30. Number of children

  31. Number of children under 6 years old

  33. Tenants name

  34. Tenants gross income

  36. Number of bedrooms

  37. Number of adults

  38. Number of children

  39. Number of children under 6 years old

  41. Tenants name

  42. Tenants gross income

  44. Number of bedrooms

  45. Number of adults

  46. Number of children

  47. Number of children under 6 years old

  49. Tenants name

  50. Tenants gross income

  54. Property owner's name

  56. Address

  57. City, State, Zip Code

  59. Telephone Number

  60. Alternate telephone number

  61. Email address

  65. PRIORITY

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

  67. Pre-1940 house with child under 3 resides

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

  71. House where child has been poisoned by lead previously

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

  75. Leave This Blank: