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Lead and Healthy Homes Program Referral Form

  1. Contact Information
  2. Owner or Renter*
  3. Property Information
  4. Borough*
  5. Is this a rental property?*
  6. Is this property currently vacant?*
  7. Is there a child under 6 that currently resides at or regularly visits this address?*
  8. Is there a pregnant woman who lives at this address?*
  9. Was this residence built before 1978?*
  10. LLHIncome
  11. Does your income fall below the limits listed above? -- For Landlords: Does your tenants' income fall below the limits listed above?*
  12. Leave This Blank:

  13. This field is not part of the form submission.