 
Free Lead Based Paint Assessment
Do you qualify for a FREE lead based paint assessment?
Knoxville Lead Safe and Healthy Homes |
| PRE-SCREENING APPLICATION |
|---|
| CONTACT PERSON INFORMATION |
Name
|
Street Address
|
City
|
Zip Code
|
Phone #
|
Secondary Phone # (if available)
|
| INFORMATION ABOUT HOME & CHILDREN |
Do you
Own
Rent * |
Was the home built before 1978?
Yes
No
Unknown |
Does an unborn child or child under the age of 6 live at this address?
Yes
No
Unknown |
If a child under the age of 6 lives at this address, what is the child's date of birth/age:
|
Does a child under the age of 6 visit this address at least 2 different days within the same week, at least 3 hours per visit totaling 6 hours per week, and combined annual visits of 60 hours per year?
Yes
No
Unknown |
If a child under the age of 6 visits this address, what is the child's date of birth/age:
|
| NOTE: Child visitation requirements are for owner occupied participants only. Child visitation requirements (the above two questions) are NOT needed for rental properties. |
|---|
| * IF YOU RENT |
* If you Rent, provide Landlord's Name:
|
* If you Rent, provide Address:
|
* If you Rent, provide Phone Number:
|
| If lead is found during the assessment free lead based paint remediation may be available. |
|---|
Your online form submission will be sent to CAC Housing & Energy Services.
We also provide a PDF of the form that you can download, fill out, print and then mail to CAC Housing & Energy Services, P.O. Box 1650, Knoxville, TN 37950-1650. Or you can take the printed PDF form to your nearest CAC neighborhood center. Please call 865-244-3080 with any questions. |