Please answer the questions below.

Lead Safe Utica Intake Form

Date *

Note: The information below will only be used to determine if you may be pre-qualified for services.

First Name *

Last Name *

Phone Number *

Alternate Phone

Address
Home Street Address *

Apt #

City *

State *

ZIP Code *

Email Address *

Language Spoken *

Are you the property owner or a renter?

What kind of property do you own or rent?

If Building, # of Units in Building

If multi-unit do you reside in property?

Do any of these apply to you?

Was your house built before 1978?

Do Any Apply to Your Home? (Check all that apply)

If furnace doesn’t work, fuel source:

Do Any of These Apply to Anyone in Your Home?

Are You or Your Family Enrolled in Any of these Program?

How Many People Live in Your Home? *

How Much is Your Rent/Mortgage Payment Each Month? *

What is the Combined Income for All Occupants in Your Home? *

If You Rent, Have You Spoken with Your Landlord about these Issues?

Are You Current on Your Mortgage/Rent?

Do you have renter’s or homeowner’s insurance?

Are You Current on Your Property Taxes/Enrolled in a Payment Program?

Are You Current on Your Utility Bills/Enrolled in a Payment Program?

Referring Organization

Make a Difference

Learn how you can help our community