Dear Lakewood Homeowner: Thank you for your ... - City of Lakewood

• Rebate cannot be issued until the work-site achieves clearance• Rebate amount cannot exceed the cost of exterior repairs completed by thehomeowner• ERCL Option B - Work That Does Not Disturb Painted Surfaces• Rebate of 20% up to $3,000 based on eligible project costs for owner occupiedpropertiesand 10% up to $3,000 based on eligible project costs for non-owner occupiedproperties• No clearance required• Rebate amount cannot exceed the cost of exterior repairs completed by thehomeowner• Tenant Questionnaire (if rental property)• Clearance Testing Consent FormSTAGE V:• Program Coordinator will review application• Project Specialist will review project receipts• Applications will be accepted or rejected based on the following factors:• The ability of the DCD to document completed work based on verifiable itemized salesslips/invoices/vendor receipts, etc. for materials and, if applicable, contractor payments/cancelledchecks• The ability of the applicant(s) to comply with all federal, state and local laws• Project Specialist will schedule an appointment to verify completed work and conduct a HousingQuality Standards (HQS) inspection if interior repairs are included in the grant/rebate calculation.• County Health Department will conduct a “Lead Paint Site Clearance” if applicable• Loan Approval Board will review application for approval• DCD will submit check request to City of Lakewood Finance Department if grant/rebate is approvedby Loan Approval BoardSTAGE VI:• Allow 6 to 10 weeks for the reimbursement process to be completed• Homeowner receives rebate check from the City of Lakewood(PLEASE NOTE: Because there is limited funding and there are no guarantees for future funding,applications will be processed on a first come, first serve basis.)IMPROVEMENT TARGET AREA GRANT CALCULATION FORMULAOWNER OCCUPIED PROPERTYOption A - (Work that disturbs painted surfaces) 30% Grant/Rebate up to $3,000 (owner occupied) based on qualifiedexterior and interior improvements. Clearance test will be required. Amount of grant/rebate must have been spent on theexterior. 15% Grant/Rebate up to $3,000 (non-owner occupied) based on qualified exterior and interiorimprovements. Clearance test will be required. Amount of grant/rebate must have been spent on the exterior.Option B - (Work that does not disturb painted surfaces) 20% Grant/Rebate up to $3,000 (owner occupied) based onqualified exterior and interior improvements. No clearance test is required. Amount of grant/rebate must have been spenton the exterior. 10% Grant/Rebate up to $3,000 (non-owner occupied) based on qualified exterior and interiorimprovements. No clearance test is required. Amount of grant/rebate must have been spent on the exterior.CITY OF LAKEWOODDIVISION OF COMMUNITY DEVELOPMENT12650 DETROIT AVENUE529-HOME 09/13/07

IMPORTANT NOTICE‣ New federal regulations regarding lead based paint went intoeffect on September 15, 2000.‣ Because federal dollars are used to fund the ImprovementTarget Area Grant/Rebate Program, applications and/orreceipts submitted after September 15, 2000 must comply withthese new laws.‣ All renovation projects which disturb painted surfaces aresubject to a clearance examination of the work site to confirmthat no lead-based paint hazards were created duringconstruction/repairs.‣ A clearance examination involves a visual assessment anddust testing to determine if work site was adequately cleanedafter construction/repairs.‣ In all cases, HUD’s “safe work practices” should be usedwhen disturbing painted surfaces.If you have any questions, please contact the Division of CommunityDevelopment at 529-4663.

ProtectYourFamilyFromLead InYourHomeUnited StatesEnvironmentalProtection AgencyUnited StatesConsumer ProductSafety CommissionUnited StatesDepartment of Housingand Urban Development

Are You Planning To Buy, Rent, or Renovatea Home Built Before 1978?Many houses and apartments built before 1978 havepaint that contains high levels of lead (called leadbasedpaint). Lead from paint, chips, and dust canpose serious health hazards if not taken care of properly.OWNERS, BUYERS, and RENTERS areencouraged to check for lead (see page 6)before renting, buying or renovating pre-1978 housing.Federal law requires that individuals receive certaininformation before renting, buying, or renovatingpre-1978 housing:LANDLORDS have to disclose known informationon lead-based paint and lead-basedpaint hazards before leases take effect.Leases must include a disclosure aboutlead-based paint.SELLERS have to disclose known informationon lead-based paint and lead-basedpaint hazards before selling a house. Salescontracts must include a disclosure aboutlead-based paint. Buyers have up to 10days to check for lead.RENOVATORS disturbing more than 2 squarefeet of painted surfaces have to give youthis pamphlet before starting work.

IMPORTANT!Lead From Paint, Dust, andSoil Can Be Dangerous If NotManaged ProperlyFACT: Lead exposure can harm youngchildren and babies even before theyare born.FACT: Even children who seem healthy canhave high levels of lead in their bodies.FACT: People can get lead in their bodies bybreathing or swallowing lead dust, or byeating soil or paint chips containinglead.FACT: People have many options for reducinglead hazards. In most cases, lead-basedpaint that is in good condition is not ahazard.FACT: Removing lead-based paint improperlycan increase the danger to your family.If you think your home might have leadhazards, read this pamphlet to learn somesimple steps to protect your family.1

Lead Gets in the Body in Many WaysChildhoodleadpoisoningremains amajorenvironmentalhealthproblem inthe U.S.Even childrenwho appearhealthy canhave dangerouslevels oflead in theirbodies.People can get lead in their body if they:◆ Breathe in lead dust (especially duringrenovations that disturb paintedsurfaces).◆ Put their hands or other objectscovered with lead dust in their mouths.◆ Eat paint chips or soil that containslead.Lead is even more dangerous to childrenunder the age of 6:◆ At this age children’s brains and nervoussystems are more sensitive to the damagingeffects of lead.◆ Children’s growing bodies absorb morelead.◆ Babies and young children often puttheir hands and other objects in theirmouths. These objects can have leaddust on them.Lead is also dangerous to women ofchildbearing age:◆ Women with a high lead level in theirsystem prior to pregnancy would exposea fetus to lead through the placentaduring fetal development.2

Lead’s EffectsIt is important to know that even exposureto low levels of lead can severely harmchildren.In children, lead can cause:◆ Nervous system and kidney damage.◆ Learning disabilities, attention deficitdisorder, and decreased intelligence.◆ Speech, language, and behaviorproblems.◆ Poor muscle coordination.◆ Decreased muscle and bone growth.◆ Hearing damage.While low-lead exposure is mostcommon, exposure to high levels oflead can have devastating effects onchildren, including seizures, unconsciousness,and, in some cases, death.Although children are especiallysusceptible to lead exposure, leadcan be dangerous for adults too.In adults, lead can cause:◆ Increased chance of illness duringpregnancy.◆ Harm to a fetus, including braindamage or death.◆ Fertility problems (in men and women).◆ High blood pressure.◆ Digestive problems.◆ Nerve disorders.◆ Memory and concentration problems.◆ Muscle and joint pain.SlowedGrowthDigestiveProblemsReproductiveProblems(Adults)Brain or Nerve DamageLead affectsthe body inmany ways.HearingProblems3

Where Lead-Based Paint Is FoundIn general,the older yourhome, themore likely ithas leadbasedpaint.Many homes built before 1978 have leadbasedpaint. The federal governmentbanned lead-based paint from housing in1978. Some states stopped its use evenearlier. Lead can be found:◆ In homes in the city, country, or suburbs.◆ In apartments, single-family homes, andboth private and public housing.◆ Inside and outside of the house.◆ In soil around a home. (Soil can pick uplead from exterior paint or other sourcessuch as past use of leaded gas in cars.)Checking Your Family for LeadGet yourchildren andhome testedif you thinkyour homehas high levelsof lead.To reduce your child's exposure to lead,get your child checked, have your hometested (especially if your home has paintin poor condition and was built before1978), and fix any hazards you may have.Children's blood lead levels tend to increaserapidly from 6 to 12 months of age, andtend to peak at 18 to 24 months of age.Consult your doctor for advice on testingyour children. A simple blood test candetect high levels of lead. Blood tests areusually recommended for:◆ Children at ages 1 and 2.◆ Children or other family members whohave been exposed to high levels of lead.◆ Children who should be tested underyour state or local health screening plan.Your doctor can explain what the test resultsmean and if more testing will be needed.4

Identifying Lead HazardsLead-based paint is usually not a hazard ifit is in good condition, and it is not on animpact or friction surface, like a window. Itis defined by the federal government aspaint with lead levels greater than or equalto 1.0 milligram per square centimeter, ormore than 0.5% by weight.Deteriorating lead-based paint (peeling,chipping, chalking, cracking or damaged)is a hazard and needs immediate attention.It may also be a hazard when found on surfacesthat children can chew or that get alot of wear-and-tear, such as:◆ Windows and window sills.◆ Doors and door frames.◆ Stairs, railings, banisters, and porches.Lead frompaint chips,which youcan see, andlead dust,which youcan’t alwayssee, can bothbe serioushazards.Lead dust can form when lead-based paint is scraped, sanded, orheated. Dust also forms when painted surfaces bump or rub together.Lead chips and dust can get on surfaces and objects that peopletouch. Settled lead dust can re-enter the air when people vacuum,sweep, or walk through it. The following two federal standards havebeen set for lead hazards in dust:◆ 40 micrograms per square foot (µg/ft 2 ) and higher for floors,including carpeted floors.◆ 250 µg/ft 2 and higher for interior window sills.Lead in soil can be a hazard when children play in bare soil orwhen people bring soil into the house on their shoes. The followingtwo federal standards have been set for lead hazards in residentialsoil:◆ 400 parts per million (ppm) and higher in play areas of bare soil.◆ 1,200 ppm (average) and higher in bare soil in the remainder ofthe yard.The only way to find out if paint, dust and soil lead hazards exist isto test for them. The next page describes the most common methodsused.5

Checking Your Home for LeadJust knowingthat a homehas leadbasedpaintmay not tellyou if thereis a hazard.You can get your home tested for lead inseveral different ways:◆ A paint inspection tells you whether yourhome has lead-based paint and where itis located. It won’t tell you whether or notyour home currently has lead hazards.◆ A risk assessment tells you if your homecurrently has any lead hazards from leadin paint, dust, or soil. It also tells you whatactions to take to address any hazards.◆ A combination risk assessment andinspection tells you if your home hasany lead hazards and if your home hasany lead-based paint, and where thelead-based paint is located.Hire a trained and certified testing professionalwho will use a range of reliablemethods when testing your home.◆ Visual inspection of paint conditionand location.◆ A portable x-ray fluorescence (XRF)machine.◆ Lab tests of paint, dust, and soilsamples.There are state and federal programs inplace to ensure that testing is done safely,reliably, and effectively. Contact your stateor local agency (see bottom of page 11) formore information, or call 1-800-424-LEAD(5323) for a list of contacts in your area.Home test kits for lead are available, butmay not always be accurate. Consumersshould not rely on these kits before doingrenovations or to assure safety.6

What You Can Do Now To ProtectYour FamilyIf you suspect that your house has leadhazards, you can take some immediatesteps to reduce your family’s risk:◆ If you rent, notify your landlord ofpeeling or chipping paint.◆ Clean up paint chips immediately.◆ Clean floors, window frames, windowsills, and other surfaces weekly. Use amop or sponge with warm water and ageneral all-purpose cleaner or a cleanermade specifically for lead. REMEMBER:NEVER MIX AMMONIA AND BLEACHPRODUCTS TOGETHER SINCE THEYCAN FORM A DANGEROUS GAS.◆ Thoroughly rinse sponges and mopheads after cleaning dirty or dustyareas.◆ Wash children’s hands often, especiallybefore they eat and before nap timeand bed time.◆ Keep play areas clean. Wash bottles,pacifiers, toys, and stuffed animalsregularly.◆ Keep children from chewing windowsills or other painted surfaces.◆ Clean or remove shoes beforeentering your home to avoidtracking in lead from soil.◆ Make sure children eatnutritious, low-fat meals highin iron and calcium, such asspinach and dairy products.Children with good diets absorbless lead.7

Reducing Lead Hazards In The HomeRemovingleadimproperlycan increasethe hazard toyour familyby spreadingeven morelead dustaround thehouse.Always use aprofessional whois trained toremove leadhazards safely.8In addition to day-to-day cleaning and goodnutrition:◆ You can temporarily reduce lead hazardsby taking actions such as repairing damagedpainted surfaces and planting grassto cover soil with high lead levels. Theseactions (called “interim controls”) are notpermanent solutions and will need ongoingattention.◆ To permanently remove lead hazards,you should hire a certified lead “abatement”contractor. Abatement (or permanenthazard elimination) methodsinclude removing, sealing, or enclosinglead-based paint with special materials.Just painting over the hazard with regularpaint is not permanent removal.Always hire a person with special trainingfor correcting lead problems—someonewho knows how to do this work safely andhas the proper equipment to clean upthoroughly. Certified contractors will employqualified workers and follow strict safetyrules as set by their state or by the federalgovernment.Once the work is completed, dust cleanupactivities must be repeated until testingindicates that lead dust levels are below thefollowing:◆ 40 micrograms per square foot (µg/ft 2 )for floors, including carpeted floors;◆ 250 µg/ft 2 for interior windows sills; and◆ 400 µg/ft 2 for window troughs.Call your state or local agency (see bottomof page 11) for help in locating certifiedprofessionals in your area and to see iffinancial assistance is available.

Remodeling or Renovating a Home WithLead-Based PaintTake precautions before your contractor oryou begin remodeling or renovating anythingthat disturbs painted surfaces (suchas scraping off paint or tearing out walls):◆ Have the area tested for lead-basedpaint.◆ Do not use a belt-sander, propanetorch, high temperature heat gun, dryscraper, or dry sandpaper to removelead-based paint. These actions createlarge amounts of lead dust and fumes.Lead dust can remain in your homelong after the work is done.◆ Temporarily move your family (especiallychildren and pregnant women)out of the apartment or house untilthe work is done and the area is properlycleaned. If you can’t move yourfamily, at least completely seal off thework area.◆ Follow other safety measures toreduce lead hazards. You can find outabout other safety measures by calling1-800-424-LEAD. Ask for the brochure“Reducing Lead Hazards WhenRemodeling Your Home.” This brochureexplains what to do before, during,and after renovations.If you have already completed renovationsor remodeling that could havereleased lead-based paint or dust, getyour young children tested and followthe steps outlined on page 7 of thisbrochure.If notconductedproperly,certain typesof renovationscanrelease leadfrom paintand dust intothe air.9

Other Sources of LeadWhile paint, dust,and soil are themost commonsources of lead,other leadsources also exist.◆ Drinking water. Your home might haveplumbing with lead or lead solder. Callyour local health department or watersupplier to find out about testing yourwater. You cannot see, smell, or tastelead, and boiling your water will not getrid of lead. If you think your plumbingmight have lead in it:• Use only cold water for drinking andcooking.• Run water for 15 to 30 secondsbefore drinking it, especially if youhave not used your water for a fewhours.◆ The job. If you work with lead, youcould bring it home on your hands orclothes. Shower and change clothesbefore coming home. Launder your workclothes separately from the rest of yourfamily’s clothes.◆ Old painted toys and furniture.◆ Food and liquids stored in lead crystalor lead-glazed pottery or porcelain.◆ Lead smelters or other industries thatrelease lead into the air.◆ Hobbies that use lead, such as makingpottery or stained glass, or refinishingfurniture.◆ Folk remedies that contain lead, such as“greta” and “azarcon” used to treat anupset stomach.10

For More InformationThe National Lead Information CenterCall 1-800-424-LEAD (424-5323) to learnhow to protect children from lead poisoningand for other information on lead hazards.To access lead information via the web, visitwww.epa.gov/lead andwww.hud.gov/offices/lead/.EPA’s Safe Drinking Water HotlineCall 1-800-426-4791 for information aboutlead in drinking water.Consumer Product SafetyCommission (CPSC) HotlineTo request information on lead inconsumer products, or to report anunsafe consumer product or a product-relatedinjury call 1-800-638-2772, or visit CPSC's Web site at:www.cpsc.gov.Health and Environmental AgenciesSome cities, states, and tribes havetheir own rules for lead-based paintactivities. Check with your local agency tosee which laws apply to you. Most agenciescan also provide information on finding alead abatement firm in your area, and onpossible sources of financial aid for reducinglead hazards. Receive up-to-date addressand phone information for your local contactson the Internet at www.epa.gov/leador contact the National Lead InformationCenter at 1-800-424-LEAD.For the hearing impaired, call the Federal InformationRelay Service at 1-800-877-8339 to access any ofthe phone numbers in this brochure.11

EPA Regional OfficesYour Regional EPA Office can provide further information regardingregulations and lead protection programs.EPA Regional OfficesRegion 1 (Connecticut, Massachusetts,Maine, New Hampshire, Rhode Island,Vermont)Regional Lead ContactU.S. EPA Region 1Suite 1100 (CPT)One Congress StreetBoston, MA 02114-20231 (888) 372-7341Region 2 (New Jersey, New York,Puerto Rico, Virgin Islands)Regional Lead ContactU.S. EPA Region 22890 Woodbridge AvenueBuilding 209, Mail Stop 225Edison, NJ 08837-3679(732) 321-6671Region 3 (Delaware, Maryland,Pennsylvania, Virginia, Washington DC,West Virginia)Regional Lead ContactU.S. EPA Region 3 (3WC33)1650 Arch StreetPhiladelphia, PA 19103(215) 814-5000Region 4 (Alabama, Florida, Georgia,Kentucky, Mississippi, North Carolina,South Carolina, Tennessee)Regional Lead ContactU.S. EPA Region 461 Forsyth Street, SWAtlanta, GA 30303(404) 562-8998Region 5 (Illinois, Indiana, Michigan,Minnesota, Ohio, Wisconsin)Regional Lead ContactU.S. EPA Region 5 (DT-8J)77 West Jackson BoulevardChicago, IL 60604-3666(312) 886-6003Region 6 (Arkansas, Louisiana, NewMexico, Oklahoma, Texas)Regional Lead ContactU.S. EPA Region 61445 Ross Avenue, 12th FloorDallas, TX 75202-2733(214) 665-7577Region 7 (Iowa, Kansas, Missouri,Nebraska)Regional Lead ContactU.S. EPA Region 7(ARTD-RALI)901 N. 5th StreetKansas City, KS 66101(913) 551-7020Region 8 (Colorado, Montana, NorthDakota, South Dakota, Utah, Wyoming)Regional Lead ContactU.S. EPA Region 8999 18th Street, Suite 500Denver, CO 80202-2466(303) 312-6021Region 9 (Arizona, California, Hawaii,Nevada)Regional Lead ContactU.S. Region 975 Hawthorne StreetSan Francisco, CA 94105(415) 947-4164Region 10 (Alaska, Idaho, Oregon,Washington)Regional Lead ContactU.S. EPA Region 10Toxics Section WCM-1281200 Sixth AvenueSeattle, WA 98101-1128(206) 553-198512

CPSC Regional OfficesYour Regional CPSC Office can provide further information regardingregulations and consumer product safety.Eastern Regional CenterConsumer Product Safety Commission201 Varick Street, Room 903New York, NY 10014(212) 620-4120Western Regional CenterConsumer Product Safety Commission1301 Clay Street, Suite 610-NOakland, CA 94612(510) 637-4050Central Regional CenterConsumer Product Safety Commission230 South Dearborn Street, Room 2944Chicago, IL 60604(312) 353-8260HUD Lead OfficePlease contact HUD's Office of Healthy Homes and Lead HazardControl for information on lead regulations, outreach efforts, andlead hazard control and research grant programs.U.S. Department of Housing and Urban DevelopmentOffice of Healthy Homes and Lead Hazard Control451 Seventh Street, SW, P-3206Washington, DC 20410(202) 755-1785This document is in the public domain. It may be reproduced by an individual ororganization without permission. Information provided in this booklet is basedupon current scientific and technical understanding of the issues presented andis reflective of the jurisdictional boundaries established by the statutes governingthe co-authoring agencies. Following the advice given will not necessarily providecomplete protection in all situations or against all health hazards that canbe caused by lead exposure.U.S. EPA Washington DC 20460EPA747-K-99-001U.S. CPSC Washington DC 20207 June 2003U.S. HUD Washington DC 2041013

Simple Steps To Protect Your FamilyFrom Lead HazardsIf you think your home has highlevels of lead:◆ Get your young children tested for lead, even ifthey seem healthy.◆ Wash children’s hands, bottles, pacifiers, and toysoften.◆ Make sure children eat healthy, low-fat foods.◆ Get your home checked for lead hazards.◆ Regularly clean floors, window sills, and othersurfaces.◆ Wipe soil off shoes before entering house.◆ Talk to your landlord about fixing surfaces withpeeling or chipping paint.◆ Take precautions to avoid exposure to lead dustwhen remodeling or renovating (call 1-800-424-LEAD for guidelines).◆ Don’t use a belt-sander, propane torch, hightemperature heat gun, scraper, or sandpaper onpainted surfaces that may contain lead.◆ Don’t try to remove lead-based paint yourself.Recycled/RecyclablePrinted with vegetable oil based inks on recycled paper(minimum 50% postconsumer) process chlorine free.

IMPROVEMENT TARGET AREA GRANT PROGRAM(Applicants please make sure that the below listed forms have been completed and that you have attachedany requested documentation before turning in application)________________Completed application form, signed and notarizedFederal Data for Race and Ethnicity form.Request for Taxpayer Identification and Certification (W-9).Request for Exterior Property Inspection (forwarded to Building Department).____ Clearance Testing Consent Form (If submitting receipts for interior work that disturbed a paintedsurface.)____ Completed Eligible Renovation Check List (ERCL) with contractor/material receipts, invoices,etc… attached. Use the “Option A” form if your work disturbed a painted surface or the “OptionB” form if your work did not disturb a painted surface.________Signed Receipt of Lead BookletCompleted Tenant Questionnaire if your property contains rental units.Additional documentation:____Previous year’s federal tax return and attachments____ Letter, certificate or memo from the Lakewood Building Department that the exterior of yourproperty has been inspected and is in compliance.____Receipts or invoices for materials and labor.PLEASE BE ADVISED THAT YOUR APPLICATION CANNOT BE PROCESSED UNTIL ALLREQUIRED DOCUMENTATION HAS BEEN PROVIDED TO THE DIVISION OFCOMMUNITY DEVELOPMENT. CONTACT JAMES BLOCKSIDGE, PROGRAMCOORDINATOR AT 216-529-5906 IF YOU HAVE ANY QUESTIONS.

Revised 04/02/04APPLICATION FOR IMPROVEMENT TARGET AREA GRANTTO BE ASSIGNED BY THE DCDDate Filed:___________________Application Number:APPLICANTName:____________________________________ Birth Date:_____________________Address: __________________________________ Home Phone:_____________________________________________________ Work Phone:___________________Mailing Address:_______________________________ Sex: ___Female ___Male________________________________Type of Structure Single Family 2-Family 3-FamilyMarital Status: Single Married Widowed DivorcedFemale Head of Household: Yes No Number of Dependents: ________________Ethnicity & Race: Head of household, please complete form on the reverse side of this application.Yearly Household Income: __________________(As reported on your previous year’s Income Tax Form 1040, Line 35 - Adjusted Gross Income)Attachments: Previous year’s Income Tax Form Including W-2’s and All AttachmentsCitation/Commendation Letter from Building Department List of Improvements & ReceiptsCO-APPLICANTName:____________________________________Birth Date:____________________Sex: ___Female ___Male Work Phone:___________________THE UNDERSIGNED HEREBY ATTEST AND AFFIRM THE ACCURACY OF THE ABOVEPROVIDED INFORMATION, TO THE BEST OF MY (OUR) KNOWLEDGE._____________________________________________________________________Applicant SignatureCo-Applicant SignatureSUBSCRIBED AND SWORN TO BEFORE ME THIS ________ DAY OF ________________, 200___._____________________________________________NOTARYFunding is limited, and there are no guarantees for future funding.Applications will be processed on a first come, first served basis.OVER

Step 1: EthnicityHISPANIC OR LATINO:NOT HISPANIC OR LATINO:Revised 04/02/04A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish Culture or origin,regardless of race. The term “Spanish origin” can be used in addition to “Hispanic or Latino.”A person not of Cuban, Mexican, Puerto Rican, South or Central American, or Other Spanish CultureStep 2: RaceWHITE:BLACK:ASIAN:AMERICAN INDIAN/ALASKAN NATIVE:A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.A person having origins in any of the black racial groups of Africa. Terms such as “Haitian” or “Negro” can be used inaddition to “Black or African American”A person having origins in any of the original peoples of the Far East, South-East Asia, or the Indian subcontinent, forexample, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Island, Thailand and Vietnam.A person having origins in any of the original peoples of North and South America (including Central America)and who maintains tribal affiliation or community attachment.NATIVE HAWAIIAN OROTHER PACIFIC ISLANDER:A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Island.OR MULTI-RACEAMERICAN INDIAN OR ALASKA NATIVE & WHITEASIAN & WHITEBLACK OR AFRICAN AMERICAN & WHITEAMERICAN INDIAN OR ALASKA NATIVE & BLACK OR AFRICAN AMERICANOTHER MULTI-RACIALBELOW TO BE COMPLETED ONLY IF YOU ARE NOT REQUIRED TO FILE AN ANNUAL INCOME TAX RETURN:CURRENT INCOMEApplicantCo-ApplicantGross Wages/Tips ____________________________ ____________________________Pension ____________________________ ____________________________Social Security ____________________________ ____________________________Veteran’s Assist. ____________________________ ____________________________Interest Income ____________________________ ____________________________Stocks/Bonds ____________________________ ____________________________Rent ____________________________ ____________________________Other ____________________________ ________________________________________________________ ____________________________Total Income ____________________________ ____________________________TO BE COMPLETED IF THERE ARE RENTAL UNITS:UNIT #1:Tenant Name:_____________________________________UNIT #2:Tenant Name:_____________________________________UNIT #3:Tenant Name:_____________________________________Address:__________________________________________Address: __________________________________________Address:___________________________________________

CLEARANCE TESTING CONSENT FORMHomeowners seeking assistance through the Home Improvement Grant or Target AreaGrant Programs and who are submitting receipts for completed work that disturbs apainted surface must obtain clearance of the property and/or work site. The CountyHealth Department will conduct the necessary dust wipe test to determine if lead dustlevels are below Federal or State mandated levels.If the homeowner has not properly cleaned the work site and surrounding areas followingwork and prior to testing and fails clearance, the property will have to be re-cleaned andre-tested. The City of Lakewood will pay for the initial test. The cost of subsequent testsif needed will be deducted from the homeowner’s rebate. Should the homeowner’sproperty fail clearance, he/she may be required to disclose the test results at such time asthe property is sold.------------------------------------------------------------------------------------------------------------I hereby request that the County Health Department conduct the necessary clearancetesting as required by the State and Federal Lead Paint Regulations.Name: ________________________________________________________________Mailing Address:________________________________________________________Property Address: _______________________________________________________Lakewood, OH 44107Home Phone: _______________________ Work Phone:_________________________________________________________Homeowner Signature________________________________Homeowner Signature09/13/07

NOTE: Prohibited Repairs Include, but are not limited to: Aluminum/Vinyl Siding,Vinyl Replacement Windows, Glass Block Windows, and Asphalt Shingles for TileRoofs.EXTERIOR RENOVATIONS(Permits may be required; Contractors must be registered.)ELIGIBLE RENOVATION CHECK LIST (ERCL) 9/13/2007Rebates for improvements which alter the exterior of your home must receivewritten approval from the DCD prior to construction. These improvements include,but are not limited to, Room Additions, Dormers, and Porch EnclosuresOPTION A - WORK THAT DISTURBS PAINTED SURFACES - REQUIRES LEAD PAINT CLEARANCE TEST OF WORK SITEINTERIOR RENOVATIONS(Permits may be required; Contractors must be registered.)DCDDCDHOME IMPROVEMENT MATERIAL INVOICE/ APPROVED HOME IMPROVEMENT MATERIAL INVOICE/ APPROVEDCONTRACT COST R.S. DATE CONTRACT COST R.S. DATECarpentry RepairsBathChimney RepairsCarpetDrivewayCarpentryExterior PaintingCeiling InsulationFenceElectricalPorch RepairsFloorsGarage RepairsFurnaceGutters/DownspoutsHot Water TankLandscapeInsulationLatticeKitchenPorch RepairsPaintingStepsPlaster RepairsStorm DoorsPlumbingStorm WindowsWall InsulationWaterproof Basement:OtherOtherTOTAL SUBMITTED:TOTAL APPROVED:TOTAL SUBMITTED:TOTAL APPROVED:ATTACH ITEMIZED & DATED RECEIPTS, CONTRACTS, PERMITS, CANCELED CHECKS.NAME:ADDRESS:ATTACH ITEMIZED & DATED RECEIPTS, CONTRACTS, PERMITS, CANCELED CHECKS.PHONE #:DATE:Office use only: TOTAL PROJECT COST $____________ Percent of Grant Cal: ____________%TOTAL GRANT AMOUNT $__________ Initials: ____________UPON COMPLETION, HOUSE MUST CONFORM TO HOUSING QUALITY STANDARDS

ELIGIBLE RENOVATION CHECK LIST (ERCL)9/13/2007NOTE: Prohibited Repairs Include, but are not limited to: Aluminum/Vinyl Siding,Vinyl Replacement Windows, Glass Block Windows, and Asphalt Shingles for TileRoofs.EXTERIOR RENOVATIONS(Permits may be required; Contractors must be registered.)Rebates for improvements which alter the exterior of your home must receivewritten approval from the DCD prior to construction. These improvements include,but are not limited to, Room Additions, Dormers, and Porch EnclosuresOPTION B - WORK THAT DOES NOT DISTURB PAINTED SURFACES - NO CLEARANCE TEST REQUIREDINTERIOR RENOVATIONS(Permits may be required; Contractors must be registered.)HOME IMPROVEMENT MATERIAL INVOICE/ DCD HOME IMPROVEMENT MATERIAL INVOICE/ DCDCONTRACT COST APPROVED CONTRACT COST APPROVEDChimney RepairsCarpetDrivewayHot Water TankFenceFurnaceGarage ReplacementInsulation - Atticw/perimeter landscapeElectrical (non-invasive)LandscapePlumbing (non-invasive)RoofOtherOther:TOTAL SUBMITTED:TOTAL APPROVED:TOTAL SUBMITTED:TOTAL APPROVED:ATTACH ITEMIZED & DATED RECEIPTS, CONTRACTS, PERMITS, CANCELED CHECKS.NAME:ADDRESS:ATTACH ITEMIZED & DATED RECEIPTS, CONTRACTS, PERMITS, CANCELED CHECKS.PHONE #:DATE:Office use only: Total Project Cost: $__________ Percent of Grant Cal. __________%Total Grant Amount: $__________ Initials: __________UPON COMPLETION, HOUSE MUST CONFORM TO HOUSING QUALITY STANDARDS

FORM ONEAfter carefully reading the booklet “Protect YourFamily From Lead in Your Home,” sign and detachthis Receipt and return it to the City of Lakewood,Division of Community Development Office, 12650Detroit Avenue.RECEIPT OF LEAD BOOKLETI have received a copy of the booklet entitled:PROTECT YOUR FAMILY FROM LEADIN YOUR HOMEPrint Full Name_____________________________________Signature_____________________________________Address and Apt. #_____________________________________Date:09/13/07

REQUEST FOR EXTERIOR PROPERTY INSPECTIONIMPROVEMENT TARGET AREA (ITA)GRANT/REBATE PROGRAM PARTICIPANTDate:To:Re:_______________________________________Jeff Fillar, Assistant Building Commissioner- ResidentialLakewood Building DepartmentRequest for Exterior Property Inspection______________________________________________________________________________I am requesting that the Lakewood Building Department conduct an exterior inspection of myproperty.This inspection is being requested in conjunction with my intention to apply to the Division ofCommunity Development for participation in their Grant/Rebate Program.I am aware that I will be responsible to correct any citations issued by the BuildingDepartment as a result of this property inspection.Homeowner Name: __________________________________________________________(please print)__________________________________________________________Property Address: __________________________________________________________Phone #:__________________________________________________________Homeowner Signature(s):________________________________________________________________________________Mail To:Building DepartmentCity of Lakewood12650 Detroit AvenueLakewood, OH 4410709/13/07

TENANT QUESTIONNAIREFORRENTAL PROPERTYHOMEOWNER:_____________________________________________________________________Name of Tenant(s):____________________________________________________________________________________________________________________Property Address: _____________________________________________________________How many people (include all children and adults) live in your unit?: ____________________Marital Status: ___ Married ___ Divorced ____ Widowed ____ SingleAge: ___ Under 60 ___ Over 60Are you a female head of household? ____ Yes ____ NoRace:Please complete the back of this form.Yearly Family Income of Tenant(s): $___________________I hereby certify that the above information isaccurate and correct to the best of my knowledge.X___________________________DateX______________________________________Tenant Print NameX______________________________________Tenant Signature(NOTE: Tenant can mail this form directly to the Division of Community Development, 12650Detroit Avenue, Lakewood, OH 44107)09/20/07