Pre-application for Lead Safe Housing Program

Pre-application for Lead Safe Housing Program

Instructions

The Salt Lake County Lead Safe Housing program aims to protect families from the dangers of lead-based paint poisoning. You must be a resident of Salt Lake County to apply.

Please complete the short pre-application form below and we will notify you if you are eligible for the FREE services offered through this program.

Para aplicar en Español oprima aquí.

First name*

Last name*

Preferred language*

Street address*

City*

Select

ZIP*

Best phone number to reach you*

Phone

Best email address to reach you

How did you hear about this program?*

Select

Other way you heard about the program

Household information

Are you living in a home or rental built before 1978?*

Yes / Sí

Don't know / No se

Are you the home owner or a renter?*

Owner / Propietario

Renter / Inquilino

Do you own multiple properties?*

Yes / Sí

Are there children under the age of 6 living in or visiting your home?*

Yes / Sí

Is anyone living in or visiting your home currently pregnant?*

Yes / Sí

Does anyone in your home have asthma?*

Yes / Sí

Does your household meet the income guidelines for the program? See below*

Income qualifications (annual household income):

persona menos de $68,750
personas menos de $78,550
personas menos de $88,350
personas menos de $98,150
personas menos de $106,050
personas menos de $113,900
personas menos de $121,750
personas menos de $129,600

If you have more than 8 people in your household, select "Don't know / No se."

Yes / Sí

Don't know / No se

Send me a copy of my responses

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