City of Austin Neighborhood Housing and Community Development NHCD www by rockman10

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    City of Austin/ Neighborhood Housing and Community Development (NHCD) www.cityofaustin.org
    Lead Hazard Control Grant, administered by the NHCD                                      /
    P.O. Box 1088
    Austin, Texas 78767
    512/974-3100
    512/974-3161 Fax

        The City of Austin/NHCD can assist you with “Free” stabilization of painted surfaces in your home
        containing lead-based paint in order to prevent lead poisoning in young children. A state certified lead
        hazard risk assessor will determine the services needed to stabilize the lead-based paint in your home.
        Types of work may include specialized cleaning, wet scraping and repainting, replacement,
        encapsulation, or enclosure of identified lead-based paint hazards. All work will be performed by state
        licensed lead abatement contractors.

        You qualify if:

          You own and/or occupy a home in the City of Austin that was built before 1978.

          Your household income is at or below 80% of the area’s median income.

           You have a child under 6 years of age who lives in your home or visits your home
           more than 6 hours every week.

        If all above are checked, bring the following to the Intake Interview:

          Copies of Proof of Income for all persons living in the household who are age 18 or
          older and employed, (Copies of Tax Returns for the previous 2 years preferred)
          A copy of Lease Agreement or Proof of Ownership of your home
           (i.e. Warranty Deed)
          All children under the age of 6 must have a current blood test for lead poisoning. If
          the blood test is current, bring test result information. The program nurse will provide
          a blood test during the intake interview if blood test is not current.
          A birth certificate must be presented for each child under 6 years of age at the time of
          the intake interview.
          Call to schedule an Interview.




Lead Smart Application, REVISED 4/10/2007
PART A:        Lead SMART -- Remove the Danger

   Name:
              Last                                   First                                         Middle
   Address:
                Street                                                      State      Zip         County
   Phone:                                                       Alternate:
   Date of Birth:                                Social Security #: _______-_______-_______
   Citizen of the U.S.            YES         NO If NO, please provide information below:
   Alien number A:                                              or Admission Number:
   Marital Status:       Single     Married         Divorced               Separated         Widowed
   Spouse’s Name:
                         Last                                     First                                 Middle
   Total number of persons living in household?                                        Medicaid ____ Yes ____ No

         Proof of Ownership and/or Lease Agreement is attached




PART B:        Lead SMART -- Remove the Danger
Please list all household income, list owner first. Use other lines for different sources of income. Examples of
income are as follows: Income Tax Forms(for the past 2 years), W2’s for the past 2 years, wage statements
(pay stubs for the past 90 days), unemployment, Social Security, SSI, disability or workmen’s
compensation, Pension, AFDC, TANF, or other sources.

Name                               Age      Total Gross Income              Source of Income       Relationship to Owner
                                            (Weekly, Monthly, or Yearly)




    Copies of Proof of Income are attached. Verification papers are required for all forms of household income.
    Examples are: Income Tax Forms(for the past 2 years), W2’s for the past 2 years, wage statements (pay
    stubs for the past 90 days), unemployment, Social Security, SSI, disability or workmen’s compensation,
    Pension, AFDC, TANF, or other sources.


Lead Smart Application, REVISED 4/10/2007
 PART C: Lead SMART -- Remove the Danger



 The following listed children, under 6 years of age, live in or frequently visit the property located at:
                                                       owned by
 and are in this residence not less than 6 hours every week.

              Name of Child                        Date of Birth/Age                 Your Relationship to Child




 I,                                                  do attest to the fact, that the above statement is true and that the
children listed above do live in or frequently visit the property described above not less than six (6) hours every
week. I understand that the children listed above must have their blood tested for lead poisoning before lead
remediation work can begin on that property, and I agree to have those children tested for lead through their
health care provider or by the City of Austin Health Department and provide the results of those blood tests to the
Health Department before work can begin on the property.




 Lead Smart Application, REVISED 4/10/2007
PART D: Lead SMART -- Remove the Danger

     I hereby make application to the City of Austin/NHCD’s ‘Lead Smart – Remove the Danger’ Program
     for work on the above mentioned Property.

     I further certify that I am the owner and/or occupant of the said property, and that the income I stated
     in PART B represents my total income for the past year preceding this application including the income
     of all other persons in the home.

     The income information provided in PART B is subject to verification by the City of Austin, Texas. I
     agree to submit to the City, upon request, copies of federal income tax returns, and am aware that all the
     employers may be contacted to verify income received as a result of employment.

     I hereby grant permission to the City of Austin, Texas ‘Lead Smart – Remove the Danger’ Program
     supervisors, inspectors, employees and contractors it may use to enter the premises listed in PART A to
     perform work under the Lead Smart – Remove the Danger. I hold the City of Austin, Texas harmless
     from any legal or financial claim arising from the performance of such work.

     I, the undersigned, do hereby swear under penalty of perjury that all information contained on the
     application is true and correct to the best of my knowledge and belief.

     OPTIONAL DEMOGRAPHIC INFORMATION:

       Race:            Black           Hispanic            White             Other, specify:

       Female Head of Household:                    YES               NO


     Applicant Signature                                                       Date


     Spouse Signature                                                          Date


 The work that provided the basis for this publication was supported by funding under a grant with the U.S. Department of Housing
 and Urban Development. The substance and findings of the work are dedicated to the public. The author and publisher are solely
 responsible for the accuracy of the statements and interpretations contained in this publication. Such interpretations do not necessarily
 reflect the views of the Government.

 The City of Austin is committed to compliance with the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation
 Act of 1973, as amended. Reasonable modifications and equal access to communications will be provided upon request. Please call
 974-3100 (voice) or 974-3102 (TDD) for assistance.

 The City does not discriminate on the basis of disability in the admission or access to, or treatment or employment in, its programs
 and activities. Dolores Gonzalez has been designated as the City’s ADA/Section 504 Coordinator. Her office is located at 206 East
 9th Street, Suite 14.138. If you have any questions or complaints regarding your ADA/ Section 504 rights, please call the
 ADA/Section 504 Coordinator at 974-3256 (voice) or 974-2445 (TTY).

             This publication is available in alternative formats. Please call 974-3100 (voice) 974-3102 (TDD) for assistance.




Lead Smart Application, REVISED 4/10/2007

								
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