Name:

Age:

Phone:

Name:

Age:

Municipality:

Address

Town, Zip code

(Street or Road)

How many in household:

Number of children

Ages

Have any of the children been tested for lead in the blood?

What were the result?

Number in Family

1 2 3 4 5 6 7 8

Family Income

38,650 44,200 49,700 55,200 59,650 64,050 68,450 72,900

Income data

Source

Monthly Amount

Amount Data

Ownership

Deed

Sales Agreement

Mobile Home Title

( Advise that deed holder must be willing to sign, convert to mortage or applicatiant must get regular financing unless repairs are of emergency nature )

Are there any tax liens on the property?

If yes, explain

How long have you owned the property?

Is any part of the property leased or rented out?

How old is your home?

Has any lead paint testing been done at your home?

( Was home built before or after 1978? )

Work requested

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