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.

To be eligible to apply you must reside in the borough of Norristown, 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

Norristown Borough
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