PLEASEKEEPTHISPAGEFORYOURINFORMATION

LEADHAZARD REDUCTION DEMONSTRATION PROGRAM

ISYOURHOMELEADSAFEFORCHILDREN?

TheLeadHazard Reduction Demonstration ProgramattheCity of Harrisburg – Department of Building and Housing Developmentoffersassistancetolowandmoderate-incomefamilies,aswellasRentalPropertyOwners,inmakingtheirhomeslead-safeforchildren.TheProgramhasmadeover800homeslead-safesinceApril,1995.Hundredsofyoungchildrennowliveinhousingmadeleadsafethroughourprogram.

WhatistheLeadSafeHomeProgram?

IfyouareeligiblefortheLeadSafeHomeProgram,wewillprovideaFREELeadInspectionandRiskAssessmentonyourpropertyanaverageof$2,000to$13,500inworkto makeyourhome lead-safe,includingitemssuchasnewwindows,doors,paintingandcleaning.

ToqualifyfortheLeadSafehomeProgram,youmustmeetALLofthefollowing:

□Theremustbeachildunder6yearsofageORapregnantfemaleLIVINGINthehome;

□Yourhomeislocatedin thecityofHarrisburg,ORchild/childrenunder6yearsofagewithanElevatedBloodLead(EBL)levelof5ug/dLorhigheroccupythehomeandthe homeislocatedoutsideofatargetarea.

□Yourhomeorapartmentmustbebuiltpriorto1978;

□Yourhomemustcontainatleastonebedroom;

□Thepropertytaxesonyourhomemustbepaidup-to-date.Ifapplicable,rentalpropertiesmusthavevalidrentalcertificateandnocodeviolations;

□Residing occupant income (gross) must be low or moderate;

Household
Size / Maximum
Household Income
1 / $40,600
2 / $46,400
3 / $52,200
4 / $58,000
5 / $62,650
6 / $67,300
7 / $71,950
8 / $76,600

*Eligibilityisalsobasedonconditionofhomeandestimatedcostofaddressingleadhazards.

In addition, consideration will be given to families meeting the following criteria:

Your child or a visiting child has an elevated blood lead level

Your home is occupied by a pregnant woman.

Your home was built prior to 1940.

Your home is used as an in-home daycare.

Thefollowingcommitmentsmustbemadebythehousehold:

  • Allowfieldstaffintoyourhometoinspectforleadbeforeandaftertheproject
  • Childrenunder6yearsoldmusthavebloodtestsforleadbeforeand6monthsaftertheproject.
  • Mostlikely,thefamilymustmoveoutofthehomeduringprojectconstruction.
  • Mustbewillingtocontributetotheprojectinsomeway,eithermoneyorlabor.Thiscontributionmayalsocomefromotherlocalprogramsinyourarea(housingagency,communityactionagency,church,etc).

Inreturn,you’llreceiveanaverageof$2,000to$13,500inworkonyour home,including itemssuchasnewwindows,doors,paintingandcleaning.Sinceeachhomeisdifferent,thisdependsonthesizeandconditionofyourhome,aswellasthelocationwherelead-basedpaintisfound. Attheendofthework,you’llhavepeaceofmind, thatyour homeisnowsafeforyoungchildren!

HowdoestheLead Hazard Reduction Demonstration Program work?

  1. Completeanapplication,makingsuretoincludeproofofincome(Includes,butisnotlimitedto3mostrecentpaystubsorlastyear’sW2s,federalorstatetaxreturns,alimony,disability,and/orDepartmentofHumanServicesstatements).
  1. Fundingisprovidedas follows:
  2. OwnerOccupied:Grantfundswillbeprovidedtowardsleadhazardcontrol.TheLead Hazard Reduction Demonstration Programcantypicallyprovideupto$13,500ingrantfundstowardsyourproject.However,othersourcesoffundingwillbeexploredto matchtoourfunds(i.e.,fundsfromcityorcommunity,housingagency).
  1. RentalProperties:Grantfundswillbeprovidedfrom$2,000to$13,500PERUNIT,dependentuponcertaincriteriaofyourproperty.Theremainingcostsmust bepaidbytherentalpropertyowner.Ifthetotalprojectcostdoesnotexceedthegrantamountthatweareproviding,rentalpropertyownersareaskedtocontribute $500copayperunit.If the property is a vacant unit the Property Owner MUST attempt to rent to a low income to very low income family for one year. Finally, the Property Owner MUST not raise the rent for a period of three years. This three year period will not begin until the lead-safe process has passed a clearance inspection.
  1. Programfieldstaffwillcontactyoutovisitthehometoconductaninitialsitevisitandtodetermineifthehomemeetsbasichousingcodestandards.
  1. IfapprovedfortheLead Hazard Reduction Demonstration Program,afieldstaffwillcomebacktoyourhomeanddoafullleadinspection/riskassessmentatnocosttofindareasthatarehazardoustoyoungchildren.
  1. Basedonthisinspection,thefieldstaffwillwritealistdetailingwhatneedstobefixedtomakethehomelead-safe.
  1. Thefieldstaffwillbidandcontractwithastate-certifiedleadabatementcontractortoperformthework.
  1. The leadhazardreductionworktypicallytakes10-20daystocomplete.Youwillberequiredtorelocatefromthehouse duringthe lead safe interim controls. A relocation stipend will be available upon request until funds are no longer available.
Call(717) 255-6419foranapplicationandadditionalinformation.

Lead Hazard Reduction Demonstration Program Department of Building & Housing Development

10 N 2nd Street, Suite 206

Harrisburg, PA 17101

LEAD HAZARD REDUCTION DEMONSTRATION PROGRAM

APPLICATION

AseparateapplicationmustbecompletedforEACHaddressorapartment

Pleasecall(717)255-6419ifyouneedassistanceincompletingthisApplication.

PART1:PROPERTYINFORMATION

PROPERTY ADDRESS:APT #:

CITY: ZIP: COUNTY:

NUMBER OF UNITS/APARTMENT WITHIN BUILDING (If home has more than 1 unit):

APPLICATION FOR: OWNER OCCUPIED RENTAL PROPERTY IS THIS A LAND CONTRACT?

HOW DID YOU HEAR ABOUT OUR PROGRAM?

HAS THIS PROPERTY EVER BEEN ENROLLED IN A LEAD PROGRAM? IF YES, WHICH ONE?

HAS THIS PROPERTY EVER BEEN INSPECTED FOR LEAD? IF SO, BY WHOM?

DOES THIS PROPERTY CURRENTLY HAVE:  RUNNING WATER ELECTRICITY  HEAT/WORKING HEAT SOURCE?

DOES THE PROPERTY HAVE CURRENT OR PREVIOUS ROOF LEAKS? YES NO

PART2:OCCUPANTINFORMATION (If Propertyiscurrentlyvacant,pleasewrite“VACANT”.)

OCCUPANT NAME: TOTAL NUMBER LIVING IN HOUSEHOLD:

OCCUPANT TELEPHONE NUMBER: ALTERNATE TELEPHONE NUMBER:

OCCUPANT EMAIL ADDRESS: WHEN IS THE BEST TIME TO REACH YOU?

PART3:OWNER INFORMATION(Complete only if different from Occupant)

NAME:

OWNERSHIP:Individual LLCPartnershipCorporation

ADDRESS:TELEPHONE NUMBER:

CITY: STATE ZIP ALTERNATE TELEPHONE NUMBER:

If you are the LANDLORD:

Have you been cited by the local prosecutor’s office for a child’s lead poisoning?YESNO

Have you been cited by any party for non-compliance of the lead disclosure law?YESNO

Harrisburg landlords only: Is your unit currently registered with the city as a rental unit?YESNO

If yes, please attach a copy of certificate. If no, are you willing to get it registered?YESNO

Property owner, please remember to sign Page 3 of this application. We cannot proceed without your signature.

Pleasecontinuetopage2ofthisform

Program Use Only:Application Loggin InApp No: Denial:

BLL: Partnership:Denial Reason:

Income: Target Area:

Part V: Total Application:

APPROVED FOR LSHP ENROLLMENT:

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PART4: OCCUPANT DETAIL: Pleasecomplete the tablebelow.

  • All occupants,adult and children,must be listedandinformationcomplete. Attachanadditional sheetof paper,if necessary.
  • ThisProgramrequiresthatallchildren under 6 years old be testedfor blood lead poisoning beforeand afterlead reduction workis done onyour home. Contact your doctor orcountyhealth department toarrange forbloodtests.Thisinformationwill be treatedasconfidential.
  • Homeswithchildrenunder6 yearsofage(Age birthto 5)withanElevatedBloodLead (EBL)levelwill be givenhigherpriority.
  • Proof of incomeshould be listed forall those who are 18years ofage and older withinthehousehold.

TheDepartment of Building & Housing Developmentdoesnotdiscriminateagainstanyindividualor group because of race, sex,religion, age,nationalorigin, color,marital status,disabilityor politicalbelief.

NAME / MEDICAID(YES ORNO) / GROSSINCOMEPERMONTH(BEFORETAXES) / DATEOF BIRTH / RELATIONTO PRIMARYRESIDENT / LEAD TEST RESULT
(Foragesbirth to 5yearsold) / Hasthispersonbeen toldbya doctor/nursethathe/she hasasthma? / Number oftimesthispersonvisited ERinlastyearforasthma: / Number oftimesthisperson washospitalizedinlastyearforasthma: / HISPANIC
/ LATINO
(YES ORNO) / RACE
A-ASIANB-BLACKW-WHITE
H-HAWAIIAN/PACIFICISLANDER
I-AMERICANINDIAN/ALASKAN
TOTAL HOUSEHOLDINCOME(Add
LinesAbove)

PLEASECOMPLETETHEATTACHEDINCOMECHECKLISTANDPROVIDE PROOFOFINCOMEFOR ALL HOUSEHOLDINCOME RECEIVED

Pleasecontinuetopage3ofthisform.

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PART5: ELIGIBILTY

Please answer ALLofthe followingquestions, bychecking “Yes”, “No” or “Don’t Know”.
Failureto provideinformation will bereason fordenial.Pleasecall(717)255-6419ifyou needassistance. / Yes / No / Don’t
Know / ProgramUse Only
1. Was thehouseat the above address built before 1978?Approximate Year Built
2. Areproperty taxes paid upthroughthe last billingcycle? / Programuse: Paid Not Paid
Date Verified
3. Is thehouse/apartment owned bya federal, state,orlocal governmentagency?
4. Does the house/apartment have at least onebedroom?
5. Do youagree to have your children under 6 yearsoldtested forlead poisoning 6 monthsfollowing lead work?
6. Is this property or tenant currently participating in a HUD program?If yes, which one?
7. Do you or the property owner have homeowner’s and/or renter’s insurancethatcovers theftandfire?
8.Is there a childunderthe ageof6 livinginthe housefull time?If yes,howmany?
9.Is there a childundertheage of6 whois a regular visitor(for at least six hours perweek,ten weeks peryear)?
Pleasenote,a childresidentor pregnantfemalelivinginthepropertyisrequiredforenrollmentinthisprogram.
10. Is there a child under 6 livingin ora regularvisitortothis homewithabloodleadlevel of5 orhigher?
11.If you are theowner, wouldyou bewilling tocontribute cash or labor towards thisproject?
12.Is there a pregnantwomanliving atthisaddress?
13.Is there a womanliving at thisaddress betweenthe agesof 16 and 45?
14.Doyou understand that your household may be askedto relocatefor upto 10 dayswhile work occurs?
15.Is thishome being usedas aday care? If so, howmany childrenattend?
16.Was thishomebuilt prior to 1940?
17.How longhave youlived at thisaddress? / Years
Months
18. If youare a tenantandcurrently renting, pleaselistthemonthly amountyou pay forrent. / $/month

By signing below,thePARENT/GUARDIANauthorizes the DBHD, Lead Hazard Reduction Demonstration Programto obtain blood leadlaboratory results onthechildrenundersixyears ofageresidingintheunitandsharetheseresultsconfidentially withauthorized program representatives. By signing below,theoccupantandproperty ownerauthorizestheDBHD, Lead Hazard Reduction Demonstration Program toperforma Lead Inspection and Risk Assessmentonsaid property andwill cooperate fully inthepotential lead hazard abatementwork.I verifythat the answersprovided above are accuratetothe bestofmy knowledge.Penaltyforfalseorfraudulent statements:U.S.C. Title 18,sec1001, provides:“Whoever,in anymatterwithin the jurisdiction ofany department oragencyof the United States knowinglyfalsifies,ormakes,or usesanyfalse writing or document knowing the same tocontain anyfalse, fictitious or fraudulentstatementor entry,shallbe finednotmorethan $10,000 orimprisoned not morethan five years,or both.”

Owner/Landlord Name(please print)Owner/Landlord SignatureDate

TenantName(if applicable,pleaseprint)TenantSignature(ifapplicable)Date

Mailcompletedapplicationand income informationto:DBHD, Lead Hazard Reduction Demonstration Program

10 N 2nd Street Suite 206 Harrisburg, PA 17101

ORFaxapplicationto(717)255-6421.PleasecontinueIncomeChecklist.

LEADHAZARD REDUCTION DEMONSTRATIONPROGRAMINCOMECHECKLIST

Pleasecall(717)255-6419ifyouneedassistance.

This form must be filledout bytheOCCUPANTofthe propertyandincomedocumentationmust be attached fortheOCCUPANTonly.

Pleasechecktheappropriateboxesifanyoneage18andolderreceivesanyofthefollowingincome.DocumentationmustbeincludedforALLITEMSCHECKEDandanyotherincomereceivedthatisnotlistedbelow:

□IRS tax forms from most recent year available – Form 1040

□Copies of 3 most current payroll stubs

□Unemployment Statement

□Disability Compensation

□Worker’s Compensation

□Child Support

□Alimony

□Severance Pay

□Aid from Department of Human Services (Cash Assistance Only)

□Supplemental Security Income (SSI)

□Copies of Social Security earnings statements

□Other annuity or retirement income statements

□Any other documented income (Including Seasonal Income)

Questions?Pleasecallusat(717)255-6419.Failuretosubmitchecklistandnecessarydocumentationmaybecauseforprogramdenial.

By signing below, theoccupantacknowledgesthat this form hasbeen completed truthfullyandto thebest ofhis/her knowledge.Penaltyforfalse orfraudulent statements:U.S.C.Title18,sec 1001, provides:“Whoever, in any matterwithinthejurisdictionofany department oragencyof theUnitedStatesknowinglyfalsifies, or makes,or usesanyfalsewriting or document knowingthesameto contain anyfalse,fictitious or fraudulentstatementorentry, shall be fined notmorethan $10,000 or imprisoned notmorethanfive years, or both.”

Occupant NameOccupant SignatureDate

Mailcompletedapplicationand income informationto:DBHD, Lead Hazard Reduction Demonstration Program

10 N 2nd Street Suite 206 Harrisburg, PA 17101

ORFaxapplicationto (717)255-6421