Low Income Radon Mitigation Assistance Program Homeowner Application

* 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.) *

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.