Healthy Homes Section P.O. Box 30195 Lansing, Michigan 48909 (517) 335-9390 LEAD SAFE HOME PROGRAM INCOME CHECKLIST Please call (866) 691-5323 if you need assistance. This form must be filled out by the OCCUPANT of the property and income documentation must be attached for the OCCUPANT only. Please check the appropriate boxes if anyone age 18 and older receives any of the following income. Documentation must be included for ALL ITEMS CHECKED and any other income received that is not listed below: tax from most recent year available Form 1040 IRS – of 3 most current payroll stubs Copies Statement Unemployment Compensation Disability Compensation Worker’s Support Child Alimony Pay Severance from Department of Human Services (Cash Assistance Only) Aid Security Income (SSI) Supplemental of Social Security earnings statements Copies annuity or retirement income statements Other other documented income (Including Seasonal Income) Any Questions? Please call us at (866) 691-5323. Failure to submit checklist and necessary documentation may be cause for program denial. By signing below, the occupant acknowledges that this form has been completed truthfully and to the best of his/her knowledge. Penalty for false or fraudulent statements: U.S.C. Title 18, sec 1001, provides: in any matter within the jurisdiction of any department or “Whoever, agency of the United States knowingly falsifies, or makes, or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years, or both.” Occupant Name Occupant Signature Date Mail completed application and income information to: MDHHS- Lead Safe Home Program PO Box 30195, Lansing, MI 48909 OR Fax application to (517) 335-8800
Healthy Homes Section P.O. Box 30195 Lansing, Michigan 48909 (517) 335-9390 LEAD SAFE HOME PROGRAM INCOME CHECKLIST Please call (866) 691-5323 if you need assistance. This form must be filled out by the OCCUPANT of the property and income documentation must be attached for the OCCUPANT only. Please check the appropriate boxes if anyone age 18 and older receives any of the following income. Documentation must be included for ALL ITEMS CHECKED and any other income received that is not listed below: IRS tax from most recent year available – Form 1040 Copies of 3 most current payroll stubs Unemployment Statement Disability Compensation Worker’s Compensation Child Support Alimony Severance Pay Aid from Department of Human Services (Cash Assistance Only) Supplemental Security Income (SSI) Copies of Social Security earnings statements Other annuity or retirement income statements Any other documented income (Including Seasonal Income) Questions? Please call us at (866) 691-5323. Failure to submit checklist and necessary documentation may be cause for program denial. By signing below, the occupant acknowledges that this form has been completed truthfully and to the best of his/her knowledge. Penalty for false or fraudulent statements: U.S.C. Title 18, sec 1001, provides: “Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly falsifies, or makes, or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years, or both.” Occupant Name Occupant Signature Date Mail completed application and income information to: MDHHS- Lead Safe Home Program PO Box 30195, Lansing, MI 48909 OR Fax application to (517) 335-8800
EBL%20Case%20Management%20Guide%20Updated%201_24_2017.docx