Lead and Healthy Homes Referral Form

This program is being organized by Montgomery County Health and Human Services and ACLAMO to prevent childhood lead poisoning and to promote lead-free, healthy housing. Please click on the infographic to the left to read about the requirements for application for this program.

Preferred Language*

English
Spanish

Contact Information

Name*

First Last

Phone*

Email*

Address*

Street Address City State ZIP Code

Owner
Renter

Property Information

Address*

Street Address City State ZIP Code

Is this a rental property?*

Yes
No

Is this property currently vacant?*

Yes
No

Is there a child under 6 that currently resides at or regularly visits this address?*

Yes
No
N/A

Is there a pregnant woman that lives at this address?*

Yes
No
N/A

Was the residence build before 1978?*

Yes
No

Income

Family Size	1	2	3	4	5	6	7	8
Pre-Tax Income	$62,500	$71,400	$80,350	$89,250	$96,400	$103,550	$110,700	$117,850

Does your income from all sources fall below the limits listed above? For Landlords: Does your tenants’ income fall below the limits listed above?*

Yes
No
N/A