Application Form

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Name*

Address*

Phone Number*

Year house was built? *

What is the annual income for the household?*

Do you own or rent the home? Yes/No*

Is the home a mobile home/trailer? Yes/No*

How many children in the home under age six? i.e. 2*

How many people live in the home?*

Protecting the families and future of Clayton, Alabama through education and proactive lead hazard reduction.

City of Clayton, Alabama | 45 Reed Avenue, Clayton, AL 36016 | cityofclaytonal@gmail.com | (334) 775-9176

Our Dedication In Preserving Our Local City

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