1. Last Name First Name MI Birth Date
2. Married Unmarried Widowed Divorced Legally Separated
3. Spouse name Birthdate
4. Names and Ages of Members of Household: Name Age Name Age Name Age Name Age Name Age Name Age
7. Do you regularly care for or host any child under the age of 6 years? Yes No If ‘Yes,’ provide: Name Age Relation to you Are these regular visits equal to or greater than 312 hours per year? Yes No
8. Besides your home/subject property, do you own other real estate? Yes No
***** The following information is requested for reporting purposes ONLY and will not be considered in evaluating your application for the 'Lead Hazard Control Program.'
9. My ethnic origin is: Hispanic Asian Black White Native American Other
10. Are you (applicant) a 'Female Head of Household'? Yes No
1. Present Employer Address
2. Spouse's Employer Address
3. Other Employer Address
1. Head of Household Gross Earnings $
2. Spouse/Adult Child Gross Earnings $
3. Veteran, Retirement Pension, Social Security, TANF, etc $
4. Other Income (Interest, Dividend, Rental, Child Support, etc) $
5. 5. TOTAL MONTHLY GROSS INCOME $
1. Does any HH member have a disability? Yes No If 'YES,' please specify
2. Why and where do you suspect the presence of lead hazards in your home?
The applicant certifies that all information in this application is given for the purpose of obtaining assistance under the 'Lead Hazard Control Program' and is true and complete to the best of the applicant’s knowledge and belief. Applicant understands that willful falsification of this information may require the applicant to reimburse the City of Tucson for the cost of repairs made to his/her house under this Program. Applicant agrees that any of the information contained in this application may be verified by any source necessary. ALL INFORMATION REMAINS CONFIDENTIAL!!
I Agree. I Do Not Agree.