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 InformationName* First Last Phone*Email* Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code * Owner Renter Property InformationAddress* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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