Lead Safe Jackson Housing Application

Step 1 of 8 - Overview

Instructions
Guidelines for Completing the Lead Safe Jackson Housing Program Application

For timely and accurate processing, please follow all of the steps listed below. If you need assistance to complete this application, please call 601-960.2155.

1) Answer all questions on the application accurately.

2) Place your signature in the appropriate spaces. (If you are a renter, you will need to ask your landlord to sign this form prior to submission. Staff members at the City of Jackson and the Office of Housing and Community Development can provide program information to landlords upon request.)

Documents to attach
REQUIRED DOCUMENTS (to be submitted with application)

(1) IRS tax forms or Form W-2 (wage and tax statement)

(2) Additional form of income verification for each household member, examples include:

□ Paystubs for the most recent 3 months

□ Social Security earnings or Supplemental Security Income statement

□ Disability or Worker’s Compensation

□ Child Support or Alimony

□ Other annuity or retirement income statements

□ Bank Statements

(3) If there are adults living in the household that are not employed, a notarized “verification of no income” form

(4) If a homeowner, proof of ownership in property (Warranty Deed, Quitclaim Deed, or Title Opinion)

(5) Driver’s license or identification card for all household members

(6) Social Security Card for all household members

(7) Blood Lead Level Test Results or Birth Certificate for children under age 6 or pregnant women occupying the home
IRS Tax Form or W-2
Accepted file types: pdf, Max. file size: 100 MB.
Additional Form of Income Verification (Paystub, Social Security earning, Child Support or Alimony, etc.)
Accepted file types: pdf, Max. file size: 100 MB.
Notarized "Verification of No Income" Form
Accepted file types: pdf, Max. file size: 100 MB.
ONLY IF someone in the HOUSEHOLD over the age of 18 does not receive income

Please copy and paste the file to access the file and submit the signed and notarized copy.

file:///C:/Users/cao-user/Documents/lsjhp%20Verification%20of%20No%20Income%20Form.pdf
Proof of Property Ownership (Warranty Deed, Quitclaim Deed, or Title Opinion)
Accepted file types: pdf, Max. file size: 100 MB.
Driver's License or Identification Card for all household members
Accepted file types: pdf, jpg, Max. file size: 100 MB.
Social Security Card for all household members
Accepted file types: pdf, jpg, Max. file size: 100 MB.
Blood Lead Level Test Results or Birth Certificates for children under age 6 or pregnant women occupying the home
Accepted file types: pdf, Max. file size: 100 MB.

Property Information
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Has this property ever been inspected for lead? * Required
- Yes
- No
If yes, when?
Name of Inspector or Inspection Firm:
Type of Occupancy: * Required
If other, please explain.
Age of Home * Required
Type of Housing Unit * Required
If other, please explain.

Property Owner Information
If property is currently renter-occupied
Primary Contact Name
First Last
Other Contact Name
First Last
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Ownership Entity:
Phone (Day)
Phone (Evening)
Email Address
Enter Email Confirm Email
Best Time to Reach You
Have you ever been cited for non-compliance with the lead disclosure law?

Household Information
I hereby declare the following person(s) live within my household for more than 51% of the time. Therefore this person or persons should be included in my household number and their income should be calculated into my household income.

If you live in a one-person household, then you must enter a child or person in the second section.
Name (Household Head) * Required
Prefix First Middle Last Suffix
Medicaid * Required
Birth Date * Required
Relationship to head of household * Required
Sex * Required
Ethnic Group * Required
Asthma Diagnosis * Required
Number of ER visits in past 12 months for asthma * Required
Number of hospitalization in past 12 months for asthma * Required
30 Day Gross Income * Required
Name (Household Member)
First Middle Last Suffix
Medicaid
Birth Date
Relationship to head of household
Sex
Ethnic Group
Lead Test Results (For ages birth to 5 years old)
Asthma Diagnosis
Number of ER visits in past 12 months for asthma
Number of hospitalization in past 12 months for asthma
30 Day Gross Income
Name (Household Member)
First Middle Last Suffix
Medicaid
Birth Date
Relationship to head of household
Sex
Ethnic Group
Lead Test Results (For ages birth to 5 years old)
Asthma Diagnosis
Number of ER visits in past 12 months for asthma
Number of hospitalization in past 12 months for asthma
30 Day Gross Income
Name (Household Member)
First Middle Last Suffix
Medicaid
Birth Date
Relationship to head of household
Sex
Ethnic Group
Lead Test Results (For ages birth to 5 years old)
Asthma Diagnosis
Number of ER visits in past 12 months for asthma
Number of hospitalization in past 12 months for asthma
30 Day Gross Income
Name (Household Member)
First Middle Last Suffix
Medicaid
Birth Date
Relationship to head of household
Sex
Ethnic Group
Lead Test Results (For ages birth to 5 years old)
Asthma Diagnosis
Number of ER visits in past 12 months for asthma
Number of hospitalization in past 12 months for asthma
30 Day Gross Income
Name (Household Member)
First Middle Last Suffix
Medicaid
Birth Date
Relationship to head of household
Sex
Ethnic Group
Lead Test Results (For ages birth to 5 years old)
Asthma Diagnosis
Number of ER visits in past 12 months for asthma
Number of hospitalization in past 12 months for asthma
30 Day Gross Income
Total of All Monthly Income * Required
If a pregnant woman and/or child under the age of 6 visits your home for at least 20 hours per week (on average), please list them in the section below. (Information reported in this section will not impact status of household size.)
Name
First Middle Last Suffix
Medicaid
Birth Date
Relationship to head of household
Sex
Ethnic Group
Lead Test Results (For ages birth to 5 years old)
Asthma Diagnosis
Number of ER visits in past 12 months for asthma
Number of hospitalization in past 12 months for asthma
30 Day Gross Income
Name
First Middle Last Suffix
Medicaid
Birth Date
Relationship to head of household
Sex
Ethnic Group
Lead Test Results (For ages birth to 5 years old)
Asthma Diagnosis
Number of ER visits in past 12 months for asthma
Number of hospitalization in past 12 months for asthma
30 Day Gross Income
Name
First Middle Last Suffix
Medicaid
Birth Date
Relationship to head of household
Sex
Ethnic Group
Lead Test Results (For ages birth to 5 years old)
Asthma Diagnosis
Number of ER visits in past 12 months for asthma
Number of hospitalization in past 12 months for asthma
30 Day Gross Income

For Occupants of the Property (renters or homeowners)
Please select yes or no for each statement.
I understand that this program requires that all children under 6 years old be tested for blood lead poisoning before and after lead reduction work is done on the home, and that I will be required to submit documents from a medical service provider that states the blood lead level of each child occupying the home. I understand that this information will be treated as confidential. * Required
I understand that program administrators may need confirmation of blood lead testing results, and I authorize the City of Jackson to obtain blood lead laboratory results for any occupants of the home required to receive testing and share these results confidentially with authorized program representatives. * Required
I understand that homes with children under 6 years of age or pregnant women with an Elevated Blood Lead Level will be given higher priority for program enrollment and scheduling of abatement activities. * Required
I understand that all occupants of the property may be required to temporarily relocate from the property while lead abatement activities are ongoing. * Required
I understand that program income eligibility for renters is 50 to 80 percent of Jackson's area median income, and for homeowners is 80 percent of Jackson's area median income, and I must provide approved forms of income documentation to demonstrate eligibility. * Required
I understand that the Green & Healthy Homes Initiative and City of Jackson will review this application for eligibility, but that none of the information included in this application or its supporting documentation will be shared with any other party unless the applicant has been notified of the Privacy Practices of the agencies and given consent in writing to do so. * Required
For Owners of the Property (homeowners or landlords)
Please select yes or no for each statement.
I understand that Lead Safe Housing registry will be used to track lead abatement and clearance activities of this and future lead programs in Jackson for all properties improved using public funding. * Required
I understand that I will be required to sign an agreement with the City of Jackson in order to participate in the Lead Safe Jackson Housing Program. * Required
(FOR LANDLORDS ONLY) By participating in this program, I agree to market the property to low income families with children under age 6 or pregnant women for a period of 3 years, and submit income verification documents to the City of Jackson during that period. * Required
Additional Information
Are property taxes paid up through the last billing cycle? * Required
Is the house/apartment owned by a federal, state, or local government agency? * Required
Does the house/apartment have at least one bedroom? * Required
Is the property and/or tenant currently participating in a HUD program? * Required
If yes, which one?
Do you or the property owner have renter's insurance that covers theft and fire? * Required
Do you or the property owner have renter's insurance that covers flood? * Required
Is there a child under the age of 6 living in the house full time? * Required
If so, how many?
Is there a child under the age of 6 who is a regular visitor (at least six hours per week, ten weeks per year)? * Required
Is there a child under the age of 6 living in or regularly visiting the home with a blood lead level of 5 or higher? * Required
Is there a pregnant woman living at this address? * Required
Is there a woman living at this address between the ages of 16 and 45? * Required
Is this home being used as a daycare? * Required
If so, how many children attend?
If you are a tenant and currently renting, please list the monthly amount you pay for rent. * Required

By signing below, I (we) certify that the income and household composition is correct to the best of my (our) knowledge and belief. I understand that by providing false information on income and household size, it will constitute a fraudulent action and my (our) application may be denied.
Owner/Landlord Name * Required
Prefix First Middle Last Suffix
Date * Required
MM slash DD slash YYYY
Tenant Name * Required
Prefix First Middle Last Suffix
Date * Required
MM slash DD slash YYYY

Lead Safe Jackson Housing Application

Step 1 of 8 - Overview

Instructions

Documents to attach

Property Information

Occupant Information

Property Owner Information

Household Information

If a pregnant woman and/or child under the age of 6 visits your home for at least 20 hours per week (on average), please list them in the section below. (Information reported in this section will not impact status of household size.)

For Occupants of the Property (renters or homeowners)

For Owners of the Property (homeowners or landlords)

Additional Information

By signing below, I (we) certify that the income and household composition is correct to the best of my (our) knowledge and belief. I understand that by providing false information on income and household size, it will constitute a fraudulent action and my (our) application may be denied.