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.

To be eligible to apply you must reside in the borough of Pottstown or Lansdale.

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

Lansdale Borough
Pottstown Borough

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	$50,500	$57,700	$64,900	$72,100	$77,900	$83,650	$89,450	$95,200

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