2. 
3. Application for:

   1. Owner Occupied

   1. Landlord

   1. Tenant
5. OCCUPANT INFORMATION
7. Primary Contact Name
9. Phone #
10. E-Mail Address
12. Property Street Address
13. City, State ZIP
15. Does Property Currently Have (check all that apply)?

    1. Running Water

    1. Electricity

    1. Heat

    1. Roof Leaks
17. Home Built Before 1978?

    1. Yes
    2. No
    3. I Don't Know
18. Monthly Rent
19. #Units in Building
21. LANDLORD INFORMATION

    1. Individual

    1. LLC

    1. Partnership

    1. Corporation
23. Landlord Name
25. Landlord Phone #
26. Landlord email
28. Landlord Street Address
29. Landlord City, State ZIP
31. Property Manager/Authorized Representative
32. Management Company
34. Phone #
35. Email
37. Is your unit currently registered with municipality as a rental unit?

    1. Yes

    1. No

    1. Not Sure
39. Total # Persons Living in Household + Children Visiting Under Age of Six
40. Total Household Income

    Include income for all persons living in the household over the age of 18.

42. 1. Household Member Full Name
    Name as it appears on Social Security card.
43. Date of Birth
    Date of Birth
44. Relation to Head of Household
46. Child Reside or Visit?

    1. Reside
    2. Visit
    3. N/A
47. Tested for Lead?

    1. Yes
    2. No
48. Race
    -- Select One --AsianBlackWhiteHawaiian/Pacific IslanderAmerican Indian/Alaskan
49. Hispanic or Latino?

    1. Yes
    2. No
51. 2. Household Member Full Name
    Name as it appears on Social Security card.
52. Date of Birth
    Date of Birth
53. Relation to Head of Household
55. Child Reside or Visit?

    1. Reside
    2. Visit
    3. N/A
56. Tested for Lead?

    1. Yes
    2. No
57. Race
    -- Select One --AsianBlackWhiteHawaiian/Pacific IslanderAmerican Indian/Alaskan
58. Hispanic or Latino?

    1. Yes
    2. No
60. 3. Household Member Full Name
    Name as it appears on Social Security card.
61. Date of Birth
    Date of Birth
62. Relation to Head of Household
64. Child Reside or Visit?

    1. Reside
    2. Visit
    3. N/A
65. Tested for Lead?

    1. Yes
    2. No
66. Race
    -- Select One --AsianBlackWhiteHawaiian/Pacific IslanderAmerican Indian/Alaskan
67. Hispanic or Latino?

    1. Yes
    2. No
69. 4. Household Member Full Name
    Name as it appears on Social Security card.
70. Date of Birth
    Date of Birth
71. Relation to Head of Household
73. Child Reside or Visit?

    1. Reside
    2. Visit
    3. N/A
74. Tested for Lead?

    1. Yes
    2. No
75. Race
    -- Select One --AsianBlackWhiteHawaiian/Pacific IslanderAmerican Indian/Alaskan
76. Hispanic or Latino?

    1. Yes
    2. No
78. 5. Household Member Full Name
    Name as it appears on Social Security card
79. Date of Birth
    Date of Birth
80. Relation to Head of Household
82. Child Reside or Visit?

    1. Reside
    2. Visit
    3. N/A
83. Tested for Lead?

    1. Yes
    2. No
84. Race
    -- Select One --AsianBlackWhiteHawaiian/Pacific IslanderAmerican Indian/Alaskan
85. Hispanic or Latino?

    1. Yes
    2. No
87. 6. Household Member Full Name
    Name as it appears on Social Security card
88. Date of Birth
    Date of Birth
89. Relation to Head of Household
91. Child Reside or Visit?

    1. Reside
    2. Visit
    3. N/A
92. Tested for Lead?

    1. Yes
    2. No
93. Race
    -- Select One --AsianBlackWhiteHawaiian/Pacific IslanderAmerican Indian/Alaskan
94. Hispanic or Latino?

    1. Yes
    2. No
96. 7. Household Member Full Name
    Name as it appears on Social Security card
97. Date of Birth
    Date of Birth
98. Relation to Head of Household
100. Child Reside or Visit?

     1. Reside
     2. Visit
     3. N/A
101. Tested for Lead?

     1. Yes
     2. No
102. Race
     -- Select One --AsianBlackWhiteHawaiian/Pacific IslanderAmerican Indian/Alaskan
103. Hispanic or Latino?

     1. Yes
     2. No
105. 8. Household Member Full Name
106. Date of Birth
     Date of Birth
107. Relation to Head of Household
109. Child Reside or Visit?

     1. Reside
     2. Visit
     3. N/A
110. Tested for Lead?

     1. Yes
     2. No
111. Race
     -- Select One --AsianBlackWhiteHawaiian/Pacific IslanderAmerican Indian/Alaskan
112. Hispanic or Latino?

     1. Yes
     2. No
114. Does a pregnant woman live in the house?

     1. Yes
     2. No
115. Name
116. Due Date
     Due Date
118. Are you a caregiver?

     1. Yes
     2. No
119. Do you operate a daycare in your home?

     1. Yes
     2. No
120. Do you babysit children in your home under age 6?

     1. Yes
     2. No
122. #Children Visiting the Home

     Only include children under age six who visit at least 6 hours per week or 60 hours per year

123. #Children with Asthma
124. #Adults with Asthma
Leave This Blank:


125. 1. Receive an email copy of this form.
126. Email address

     This field is not part of the form submission.

127. Submit

* indicates a required field