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

ZIP

Best phone number to reach you

Phone

Best email address to reach you

How did you hear about this 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

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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