LEAD HAZARD CONTROL PROGRAM INTAKE FORM



left-508000CITY OF GRAND RAPIDSHOUSING Rehabilitation PROGRAMSINTAKEStaff: FORMTEXT ?????Date: FORMTEXT ?????Application Provided (Y/N): Date: FORMCHECKBOX Mailed FORMCHECKBOX Hand DeliveredProperty Type: FORMCHECKBOX Owner-Occupied FORMCHECKBOX Rental PropertyProperty Address: FORMTEXT ????? Zip Code: FORMTEXT ?????ApplicantName: FORMTEXT ?????Daytime Phone: FORMTEXT ?????E-mail: FORMTEXT ?????Primary Language: FORMTEXT ?????Contact Address (if different): FORMTEXT ?????City: FORMTEXT ????? State: FORMTEXT ????? Zip Code: FORMTEXT ?????Corporate Name: FORMTEXT ?????How hear about this program? FORMTEXT ?????Household Information ItemOwner –Occupied Rental Units #1 #2 #3 #4Total Household Members FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Household Members Age 18 and Over FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Age of Youngest Child (Pregnant Mother?) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Any Child with Elevated Blood Lead Levels? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Annual Household Income: FORMTEXT ?????Currently involved in a bankruptcy? FORMTEXT ?????Owner occupied the home for the last 12 months (Y/N)? FORMTEXT ?????Periods of time the owner did not occupy the home: Why? FORMTEXT ?????Property InformationYear home purchased? FORMTEXT ?????Buying on a Land Contract? FORMTEXT ?????Mortgage on the property? FORMTEXT ?????Is the mortgage current (Y/N)? FORMTEXT ?????Property Taxes paid (Y/N)? FORMTEXT ?????Outstanding fees on the property? FORMTEXT ?????Property Insurance (Y/N)? FORMTEXT ?????Project InformationPrevious Rehab Project (Y/N)? FORMTEXT ?????Requested repairs: FORMTEXT ?????Type of Project: FORMCHECKBOX Home Repairs FORMCHECKBOX Lead Paint Hazard FORMCHECKBOX Repairs and Lead Paint Is there an issue with sewage (Y/N)? FORMTEXT ?????Does the furnace work (Y/N)? FORMTEXT ?????Urgent Need (Y/N)? FORMTEXT ????? ................
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