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2. Contact Information
4. First Name*
5. Last Name*
7. E-Mail*
8. Phone Number*
10. Address1
12. Address2
14. City
15. State
16. Zip
18. Owner or Renter*

    1. Owner

    1. Renter
20. Property Information
22. Address1
24. Address2
26. City
27. State
28. Zip
30. Borough*

    1. Lansdale
    2. Pottstown
    3. Norristown
31. Is this a rental property?*

    1. Yes

    1. No
33. Is this property currently vacant?*

    1. Yes
    2. No
34. Is there a child under 6 that currently resides at or regularly visits this address?*

    1. Yes
    2. No
    3. N/A
36. Is there a pregnant woman who lives at this address?*

    1. Yes
    2. No

    1. N/A
37. Was this residence built before 1978?*

    1. Yes
    2. No
39. 
41. Does your income fall below the limits listed above? -- For Landlords: Does your tenants' income fall below the limits listed above?*

    1. Yes

    1. No

    1. N/A
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43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

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