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2. Please complete this form in its entirety. If you need assistance filling out this form, contact our office at 434.799.5260 ext.2486.

   If you would like to fill out and return by mail, please use this form and return to:

   Lead Safe Danville

   427 Patton Street, Suite 205

   Danville, VA 24541

6. Your Information
8. Name*
9. Email
11. Address*
13. City*
14. State*
15. Zip*
17. Phone Number*
18. Household Income*
    -- Select One --$0 - $41,100$41,101 - $46,950$46,951 - $52,800$52,801 - $58,650$58,651 - $63,350$63,351 - $68,050$68,051 +
22. Property Information
24. Are you the:*

    1. Property Owner
    2. Tenant
25. Type of Property*

    1. Single Family
    2. Multi-Family
26. Was the home built in 1978 or earlier?*

    1. Yes
    2. No
    3. I don't know
28. Are there any children under the age of 6 residing at this address?*

    1. Yes
    2. No
30. If no children under 6 reside at the address, are there any children under 6 that spend time at this address?

    1. Yes
    2. No
32. How many persons reside at in this household?
34. You can expect to hear from the Lead Safe Office within two business days of submitting this form.
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field