Section 1 of 1 in this document

Lead Removal Program Application

Thank you for applying to the City of Bloomington’s FREE Lead-Based Paint Removal Program! You’re just one step away from making your home safer. After you submit this form, we’ll let you know if you may qualify and guide you through the next steps. This program is open to residents in the 61701 area, with priority given to households with children under 6 who live, visit, or are cared for in the home. Let’s get started!

Is Your Zip Code 61701?

Yes

Thank you for applying. Grant funds used for this program are limited to homes in the 61701 Zip Code.

Your Address

Address or Location

Phone Number

How did you hear about the program?

An Event

E-Newsletter

Web search

PeachJar

Another client

Other

If other, please list the source

Was your home built before 1978?

Yes

I Don't Know

Number Of People In Household

Estimated Household Yearly Total Income For 1 Person

Greater Than $66,550

Less Or Equal To $66,550

Estimated Household Yearly Total Income For 2 People

Greater Than $76,500

Less Or Equal To $76,500

Estimated Household Yearly Total Income For 3 People

Greater Than $85,550

Less Or Equal To $85,550

Estimated Household Yearly Total Income For 4 People

Greater Than $95,050

Less Or Equal To $95,050

Estimated Household Yearly Total Income For 5 People

Greater Than $102,700

Less Or Equal To $102,700

Estimated Household Yearly Total Income For 6 People

Greater Than $110,300

Less Or Equal To $110,300

Estimated Household Yearly Total Income For 7 People

Greater Than $117,900

Less Or Equal To $117,900

Estimated Household Yearly Total Income For 8 People

Greater Than $125,500

Less Or Equal To $125,500

Your household income is above the current income limit. Please contact City staff for additional assistance.

Do you have children under 6 years of age who either live in your home or visit regularly?

Yes

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I certify that the information provided above is true, complete, and accurate to the best of my knowledge. I understand that providing false representations herein may constitute an act of fraud. I acknowledge that the information provided is being used for the specific purpose of determining whether my household is eligible to receive assistance through the City of Bloomington Lead Based Paint Hazard Reduction Program. If eligible I will fully cooperate to obtain or provide any necessary documents to confirm the information provided.

Lead Removal Program Application

Full Name

Is Your Zip Code 61701?

Your Address

How did you hear about the program?

Was your home built before 1978?

Number Of People In Household

Estimated Household Yearly Total Income For 1 Person

Estimated Household Yearly Total Income For 2 People

Estimated Household Yearly Total Income For 3 People

Estimated Household Yearly Total Income For 4 People

Estimated Household Yearly Total Income For 5 People

Estimated Household Yearly Total Income For 6 People

Estimated Household Yearly Total Income For 7 People

Estimated Household Yearly Total Income For 8 People

Do you have children under 6 years of age who either live in your home or visit regularly?

Sign Here