Low Income Radon Mitigation Assistance Program Homeowner Application

Attention: Before you begin this form, please prepare the documents listed below. These documents must be submitted to the LIRMA program to complete your application.

Radon test results > 4 pCi/L in the home within 12 months of application.
Proof of home ownership – copy of a Warranty Deed or Deed of Trust.
Copy of a current mortgage statement.
Copy of homeowners’ previous years Federal Income Tax Form filed with the Internal Revenue Service (IRS) or other income verification.
Copy of a current Colorado Driver’s License, Identification Card or Military Identification Card for each person on the deed to the home.

* Red star indicates a required field.

Homeowner first name *

Last name *

M.I.

Co-Homeowner first name

Last name

M.I.

Address *

City *

County *

Zip code *

Phone number (Ten digits - no dashes) * 🛈

Alternate phone number (Ten digits - no dashes) 🛈

Email *

Household information:

Please enter 0 if none.

Number of adults in household *

Number of disabled adults *

Number of elderly (62 years of age or older) *

Number of children (Under 18 years of age) *

Number of disabled children *

Household adjusted gross annual income *

Property information:

1. Type of dwelling

Single family house

Manufactured home

2. One-to-four unit building

Townhouse

Condominium

3. Foundation type

4. Date home was purchased * +

5. Purchase price *

6. Year home was built *

7. Please check here if your home is under the governance of a homeowners association (HOA).
If yes, you will need an approval of the mitigation plan from the HOA.

Yes (There is an active homeowners association.)

8. Total amount presently owed on the home.
(Include first and second mortgages, loans, liens, etc.) *

Disclaimer on ancillary costs associated with radon mitigation

Costs associated with the necessary movement of homeowner belongings for system installation will be considered on a case-by-case basis. CDPHE accepts no liability for objects that are broken, misplaced, or mishandled.

Alternative radon mitigation solutions. When traditional active soil depressurization radon mitigation techniques have not been successful at reducing radon levels below 4 pCi/L, alternative HVAC-related approaches will be considered on a case-by-case basis.

The Low-Income Radon Mitigation Assistance (LIRMA) program cannot pay for expenses beyond those directly related to the installation of the radon mitigation system unless mandated by a homeowner’s association (HOA). If such expenses are deemed necessary for the safe and successful installation of the system, the homeowner must bear these costs or withdraw their application. Such expenses include but are not limited to the extermination of pests or structural modifications related to stability, accessibility, or safety.

The undersigned does hereby certify that all information above is true, accurate and complete; and does hereby authorize the Colorado Department of Public Health and Environment to make independent investigations necessary to verify any information provided on the application form. The applicant also understands that the Colorado Department of Public Health and Environment does not accredit, certify, recommend or endorse individual contractors and is not responsible for work done or liability incurred by the individuals.

Homeowner's signature *

Date * +

Co-homeowner's signature

Date +

For the purposes of this form, the Colorado Department of Public Health and Environment accepts your typed name and date as an electronic signature equivalent to your valid signature on a paper copy of the form. As such, this electronically completed form bears the same rights and responsibilities as a hand-signed form.