Healthy Homes Owner Application

Office Location: 10 Columbus Boulevard, 3rd floor (low) Hartford, CT 06106 Mailing Address: 282 Washington Street Healthy Homes Program Hartford, CT 06106 Phone: (860) 837-6234 Fax: (860) 837-6244 http://www.connecticutchildrens.org/healthyhomes

Haga clic aquí para completar esta aplicación en español:

https://app.smartsheet.com/b/form/b2b07b8c53b041fbaf6961f2768dbc3b


Before you begin...

Please note this form does NOT autosave. If you navigate away from this page before submitting your complete application, all progress will be lost. Please be sure you have all the necessary information on hand before moving forward with the application. This form is to be completed and submitted by the property owner. Please only complete if you are the owner of this property. Applications submitted by tenants will not be accepted. Thank you. You will need the property information about each home/unit including the number of people who live at the property. If the property has tenants, you will need the name and contact information for the occupant(s). You will also need to know how many children under six years of age live at the property, and how many of the children under six years of age been found with lead levels of 5 or above.

Applicant Information

Please enter the following information as it relates to the owner/applicant.

Please enter the owner/applicant's first name.

Please enter the owner/applicant's last name.

Please provide the email address of the owner/applicant.

Please provide the best phone number to reach the owner/applicant.

If applicable, please provide an alternate number to reach the owner/applicant.

Were you referred to the program?*

If yes, click the flag. If no, leave flag blank.

Do you (the owner/applicant) reside at the property?*

Street / P. O. Box

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Property Information

Please enter the following information as it relates to the property.

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Is this a rental property?*
Is this a single-family home?*
How many units are part of this property?*

Home Information

Please enter the following information as it relates to the home.

Please enter the occupant's first and last name. (If the home is vacant, please write VACANT)

Please enter the best phone number to reach the occupant.

Pregnant Occupant in the home?*
Home Child Care?*
DCF Foster Home?*

First Unit Information

Please enter the following information as it relates to the first unit. If the owner lives at this property, please use this section to complete their unit information.

Please enter the occupant's first and last name. (If the unit is vacant, please write VACANT)

Please enter the best phone number to reach the occupant.

Second Unit Information

Please enter the following information as it relates to the second unit.

Please enter the occupant's first and last name. (If the unit is vacant, please write VACANT)

Please enter the best phone number to reach the occupant.

Third Unit Information

Please enter the following information as it relates to the third unit.

Please enter the occupant's first and last name. Please enter the occupant's first and last name. (If the unit is vacant, please write VACANT)

Please enter the best phone number to reach the occupant.

Fourth Unit Information

Please enter the following information as it relates to the fourth unit.

Please enter the occupant's first and last name. (If the unit is vacant, please write VACANT)

Please enter the best phone number to reach the occupant.

Information on Additional Units

If your property contains 5 or more units, download this form to provide information about the remaining units.


You will need to download the form to your computer in order to fill it out. Once complete, upload the document in the field below.

Drag and drop files here or

Building Information

Please enter the following information as it relates to the entire building.

Have any of the children under six years of age been found with lead levels of 5 or above?*

Submit Application

Please sign your name and today's date to complete your application.

By entering your name and date in the boxes below, you are confirming that the information within this application is true.


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