Fill - Free fillable Permanent Supportive Housing (PSH) Expansion TBRA Guidelines (Lake County) PDF form

Permanent Supportive Housing (PSH) 
Expansion TBRA Guidelines 
Contents 
Background ................................................................................................................................................... 2 
Terms ........................................................................................................................................................ 2 
Program Purpose ...................................................................................................................................... 3 
Tenant Selection Policy ................................................................................................................................. 3 
Income Eligibility ....................................................................................................................................... 3 
Preference ................................................................................................................................................. 3 
Process ...................................................................................................................................................... 3 
Responsibilities ......................................................................................................................................... 4 
Unit Eligibility ................................................................................................................................................ 5 
Rent Reasonableness ................................................................................................................................ 5 
Occupancy Standards ................................................................................................................................ 5 
Housing Quality Standards ........................................................................................................................ 6 
HOME Lease Requirements ...................................................................................................................... 6 
Assistance Parameters .................................................................................................................................. 6 
Minimum and Maximum Payment ........................................................................................................... 6 
Length of TBRA Assistance ........................................................................................................................ 7 
Eligible Costs ............................................................................................................................................. 7 
Other Requirements ..................................................................................................................................... 7 
Lead-Based Paint ....................................................................................................................................... 7 
Violence Against Women Act (VAWA) ...................................................................................................... 7 
Monitoring ................................................................................................................................................ 8 
Match ........................................................................................................................................................ 8 
Appendices .................................................................................................................................................... 9 
A.  Lake County Housing Authority Payment Standards .................................................................... 9 
B.  Waukegan Housing Authority Payment Standards ....................................................................... 9 
C.  North Chicago Housing Authority Payment Standards ................................................................. 9 
D.  Rent Reasonableness Checklist and Certification ......................................................................... 9 
E.  Sample TBRA Application .............................................................................................................. 9 

F.  HQS Checklist ................................................................................................................................ 9 
G.  HOME Lease Addendum ............................................................................................................... 9 
H.  Lead Disclosure ............................................................................................................................. 9 
I.  Lead Disclosure – Spanish ............................................................................................................. 9 
J.  Lead Pamphlet – Protect Your Family From Lead In Your Home .................................................. 9 
K.  Lead Pamphlet – Proteja a su familia contra el plomo en el hogar .............................................. 9 
L.  Lake County Consortium Violence Against Women Act Policy and Emergency Transfer Plan ..... 9 
M.  VAWA Notice of Occupancy Rights Template ........................................................................... 9 
N.  VAWA Certification Form Template .............................................................................................. 9 
O.  VAWA Emergency Transfer Request Form ................................................................................... 9 
P.  VAWA Lease Addendum ............................................................................................................... 9 
Q.  Match Report ................................................................................................................................ 9 
R.  TBRA Set Up Form ......................................................................................................................... 9 
 
Background 
Terms 
By-Name List: The real-time list of individuals and families experiencing homelessness in Lake County.  
Continuum of Care (CoC): A regional or local planning body that coordinates housing and services 
funding for homeless families and individuals.  
Coordinated Entry (CE): A centralized process designed to coordinate program participant intake, 
assessment, and provision of referrals for those experiencing homelessness in Lake County.  
Lake County Coalition for the Homeless (LCCH): The regional or local planning body that coordinates 
housing and services funding for homeless families and individuals in Lake County. 
Landlord: For the purposed of this document, “Landlord” refers to a landlord who leases a unit to a 
client from the Lake County Coalition for the Homeless Coordinated Entry By-Name List for a LCCH 
housing intervention.  
Permanent Supportive Housing (PSH): A housing intervention which involves the provision of a rental 
subsidy as well as supportive services.  
Provider: For the purposed of this document, “Provider” refers to the LCCH agency that provides the 
housing intervention to the Tenant. 
Tenant: For the purposed of this document, “Tenant” refers to the client referred to the Provider by the 
Coordinated Entry By-Name List and accepted into the PSH Expansion TBRA Program.  
 

Tenant-Based Rental Assistance (TBRA): A rental subsidy (funded by the HOME Investment Partnerships

Program) that helps make up the difference between what a renter can afford to pay and the actual rent

for a home.

Total Tenant Payment (TTP): The portion of the tenant’s housing costs that is paid by the tenant,

calculated as a portion of the tenant’s adjusted gross income.

Program Purpose

The Permanent Supportive Housing (PSH) Expansion TBRA Program is intended to increase the PSH

resources in Lake County available to those who need them. The program includes funding for Tenant-

Based Rental Assistance (TBRA). The program does not fund the supportive services necessary to run a

PSH program.

Tenant Selection Policy

Income Eligibility

PSH Expansion TBRA is limited to households with incomes at or below 60% of the Area Median Income.

The 60% AMI Limit is published by HUD annually and subject to change. The below limits represent the

income limits effective as of June 28, 2019.

Income Limits

1 Person

2 Person

3 Person

4 Person

5 Person

6 Person

7 Person

8 Person

30% AMI

$18,750

$21,400

$24,100

$26,750

$28,900

$31,050

$33,200

$35,350

50% AMI

$31,200

$35,650

$40,100

$44,550

$48,150

$51,700

$55,250

$58,850

60% AMI

$37,440

$42,780

$48,120

$53,460

$57,780

$62,040

$66,300

$70,620

80% AMI

$49,950

$57,050

$64,200

$71,300

$77,050

$82,750

$88,450

$94,150

100% AMI

$62,400

$71,300

$80,200

$89,100

$96,300

$103,400

$110,500

$117,700

120% AMI

$74,880

$85,560

$96,240

106,920

$115,560

124,080

$132,600

$141,240

Tenants may increase their income after they are accepted into the program. Any Tenant whose income

rises above 80% AMI is no longer eligible for PSH Expansion TBRA and will receive a termination notice a

minimum of 30 days prior to termination of the rental assistance contract.

The Provider must ensure the client is income-eligible according to the HOME regulations. Income

certifications must be completed prior to entering into a TBRA contract with the client.

Preference

PSH Expansion is a targeted program available to individuals and families experiencing homelessness on

the Coordinated Entry By-Name List.

Process

PSH Expansion TBRA will be administered by the selected Provider.

1. A family is referred to the Provider from the CE By-name List

Income limits for 30%, 50%, 60%, and 80% AMI as published by HUD. Income limits for all other income levels are

calculated based on Very Low Income (50% AMI) limit.

2. The Provider confirms client eligibility, then transitions client into the program, including:

a. Income-qualifying the applicant.

b. Signing a contract with that client. The contract becomes effective on the lease start

date.

c. Determining the total tenant payment (amount of rent the tenant is able to pay).

d. Assisting the Tenant in the housing search, including explaining the requirements of the

program to potential landlords. The Tenant may apply to multiple units.

3. Once a Tenant is accepted into a unit, the Provider ensures compliance while transitioning the

client into the unit, including:

a. Ensuring the unit meets all eligibility requirements, including conducting rent

reasonableness assessments, checking for occupancy standards, and conducting HQS

inspections.

b. Ensuring the landlord executes a lease with the Tenant, including the HOME Lease

Addendum, and complies with VAWA requirements.

c. Executing a contract with the landlord to pay the Provider’s portion of the lease. The

Tenant pays the Total Tenant Payment (tenant portion of the rent) directly to the

landlord. The Provider pays the Provider portion of the rent directly to the landlord.

4. After the Tenant is moved in and rental payments are made, the Provider submits voucher

request forms to Lake County Community Development.

a. Voucher requests for rental payments must be accompanied by applicable tenant forms

and supporting documentation of funds expended.

b. Voucher requests for administrative costs must be accompanied by supporting

documentation of funds expended.

5. The program will be monitored once annually.

Responsibilities

The Tenant is responsible for complying with program regulations, including:

• Providing household income and asset information for the purposes of completing income

qualifications and cooperating with re-certifications as necessary.

• Permitting the Provider and Lake County to conduct HQS inspections (with reasonable notice).

• Notifying the Provider when household composition changes (i.e. a household member enters

or exits a unit).

• Utilizing the rental unit as the Tenant’s principal place of residence and solely as a resident for

the Tenant’s household.

• Other responsibilities as necessary to ensure compliance with program regulations.

The Landlord is responsible for complying with program regulations, including:

• Permitting the Provider to conduct an HQS inspection prior to unit approval.

• Executing a contract with the Provider.

• Executing a HOME Lease Addendum with each lease.

• Executing a VAWA Lease Rider with each lease.

• Should issues arise with the tenant, contacting the Provider for assistance in a timely manner

and attempting to resolve issues prior to moving forward with eviction proceedings.

• Other responsibilities as necessary to ensure compliance with program regulations.

The Provider is responsible for complying with program regulations, including:

• Income-qualifying clients when accepted into program and at least once annually thereafter.

• Executing all necessary documents with the client, including a contract.

• Executing all necessary documents with the Landlord, including a contract.

• Ensuring that the unit meets all eligibility requirements, including conducting rent

reasonableness assessments, checking for occupancy standards, and conducting HQS

inspections.

• Proving supportive services to the client that align with the best practices of PSH housing

programs.

• Supplying Lake County with the documentation necessary to process vouchers.

• Complying with Lake County monitoring activities

• Submitting Match Reports (if an eligible form of match is available)

Unit Eligibility

Tenants may use their rental assistance anywhere in Lake County but must select an eligible unit. TBRA

cannot be used outside of Lake County. For a unit to be eligible:

• The unit must meet rent reasonableness requirements

• The unit must meet occupancy standards

• The unit must meet Housing Quality Standards and be able to pass HQS inspections at move-in

and annually during term of rental assistance

• The landlord must be willing to execute the HOME Lease Addendum

• The landlord must be willing to execute the VAWA Lease Rider

Rent Reasonableness

All rents must be reviewed and approved by the Provider prior to the execution of the lease or lease

renewal. Units will not be approved unless the rent is reasonable. Rents are considered reasonable if

they are at or below the payment standard amount set by the Public Housing Agency for that

jurisdiction. Please see Appendices A-C for the payment standards for 2019 and Appendix D for a

template Rent Reasonableness Checklist and Certification.

Occupancy Standards

To be eligible, a unit must meet occupancy standards to ensure that the unit size is appropriate for the

family. Single-person households may select 0-bedroom or 1-bedroom units. For households with more

than one person, the program will assign one bedroom for each two persons within the household.

Under the following circumstances, persons will not be expected to share a bedroom:

• Persons of the opposite sex (except couples and children under age 5)

• Persons of different generations

• Live-in aides (no additional bedrooms will be provided for live-in aide’s family)

In determining appropriate unit size, exceptions can be requested in writing due to the age, sex, health,

disability, or relationship of family members. The Provider may use the Sample TBRA Application

Household Composition section to help determine occupancy (See Appendix E).

Housing Quality Standards

The unit will not be approved unless it meets Housing Quality Standards (HQS) and is able to pass HQS

inspections at move-in and annually during term of rental assistance. Please see Appendix F for an HQS

checklist.

HOME Lease Requirements

Term: The term of the lease between the tenant and the owner must be for at least one year, unless

both agree otherwise. If signing a lease for a term of less than one year, there must be a statement,

signed by both tenant and landlord, indicating both parties agree to a shorter lease term. This may be

completed on the HOME Lease Addendum (Appendix G).

Provisions: The lease may not contain the following provisions:

• Agreement by the tenant to be sued or to admit guilt, or a judgment in favor of the owner in a

lawsuit brought in connection with the lease;

• Agreement by the tenant that the owner may take, hold or sell the personal property of

household members without notice to the tenant and a court decision on the rights of the

parties (this does not apply to personal property left by the tenant after move-out);

• Agreement by the tenant not to hold the owner or its agents legally responsible for any action

or failure to act, whether intentional or negligent;

• Agreement by the tenant that the owner may institute a lawsuit without notice to the tenant;

• Agreement that the owner may evict the tenant (or other household members) without a civil

court proceeding where the tenant has the right to present a defense, or before a court decision

on the rights of the tenant and the owner;

• Agreement by the tenant to waive a trial by jury;

• Agreement by the tenant to waive the tenant’s right to appeal or otherwise challenge a court

decision; or

• Agreement by the tenant to pay attorney fees or other legal costs, even if the tenant wins in

court.

Additionally, landlords may only terminate or refuse to renew the lease of a TBRA household for good

cause, which must be clearly defined in the lease.

In order to ensure that the lease complies with the above requirements, a HOME Lease Addendum must

be executed with each lease (See Appendix G).

Assistance Parameters

Minimum and Maximum Payment

The minimum tenant payment is $0.00. Tenants with zero income do not need to pay any portion of the

rent.

The maximum TBRA payment is the difference between 30% of the household’s adjusted monthly

income and the rent limit established by the payment standard. The Provider must determine the Total

Tenant Payment according to HUD standards. For more information on calculating adjusted income and

determining Total Tenant Payment, please see the Using the Income Calculator for Rental and TBRA

Programs Webinar on the HUD Exchange https://www.hudexchange.info/trainings/courses/using-the-

income-calculator-for-rental-and-tbra-programs-webinar1/.

Length of TBRA Assistance

TBRA rental assistance contracts with individual households cannot exceed 2 years.

Eligible Costs

• Rent

• Security Deposits (up to 2 months’ rent)

• Utility Deposits

Rental Assistance:

• Rental assistance payments must be paid directly to a third-party on behalf of the household.

• Rental assistance payments must be no more than the difference between the rent for the unit

in question (including the applicable utility allowance) and 30% of the household’s adjusted

income.

• No payments may be made after termination of the lease until a family enters into a new lease.

• Rental assistance for a participant may not exceed 24 months.

Security Deposits, in accordance with 24 CFR 92.209 (j):

• The amount of HOME funds provided for a security deposit may not exceed the equivalent of

two month’s rent for the unit.

• Only a prospective tenant may apply for HOME security deposit assistance, but security deposits

must be paid directly to the landlord on behalf of the participant.

• If the security deposit is returned in part or full at the end of the lease it must return to the sub-

recipient that issued it and be counted as program income in accordance with 24 CFR 92.503.

Utility Deposits:

• Utility deposits may only be used for utilities permitted under the Section 8 utility allowance.

This includes electric, gas, water, and trash, but does not include telephone and cable television.

Other Requirements

Lead-Based Paint

The HOME TBRA Program is subject to HUD’s Lead Safe Housing Rule, Subpart M of 24 CFR 35. Please

see Appendices H-K for Lead-Based Paint Disclosure notices (English and Spanish) and Pamphlets

(English and Spanish).

Violence Against Women Act (VAWA)

The HOME TBRA Program is subject to The Violence Against Women Act, Subpart L of 24 CFR part 5. The

program must comply with the requirements are described in 24 CFR 92.359 and Lake County

Consortium’s VAWA Policy and Emergency Transfer Plan (Appendix L). As such, Providers must ensure

that the notice of occupancy rights under VAWA (Form HUD 5380 - Appendix M) and the certification

form (HUD 5382 - Appendix N), along with the emergency transfer request form (HUD 5383 – Appendix

O) is provided to individuals at the following times:

• At the time an applicant is denied rental assistance;

• At the time an applicant is provided rental assistance;

• At the time the program learns that a tenant’s Landlord intends to provide tenant a notice of

eviction; and

• At the time a tenant’s rental assistance is being terminated.

Additionally, Providers must ensure that a VAWA addendum is executed with each lease (Appendix P).

Monitoring

HOME Regulations require that TBRA programs are monitored at least annually. Any agency

administering a HOME TBRA Program, including PSH Expansion, will be subject to annual monitoring

activities that will include an inspection of each unit, a review of the client’s income certification, and a

review of the rental payments made to landlords.

Match

Providers do not need to have an eligible match source in order to be qualified to administer the PSH

Expansion Program; however, if the Provider’s supportive services are funded by a source that is eligible

for match and the cost is not being claimed as match for another program, Lake County may require the

Provider submit a Match Report (Appendix Q).

Appendices 
A.  Lake County Housing Authority Payment Standards 
B.  Waukegan Housing Authority Payment Standards 
C.  North Chicago Housing Authority Payment Standards 
D.  Rent Reasonableness Checklist and Certification  
E.  Sample TBRA Application  
F.  HQS Checklist 
G.  HOME Lease Addendum 
H.  Lead Disclosure 
I.  Lead Disclosure – Spanish 
J.  Lead Pamphlet – Protect Your Family From Lead In Your Home  
K.  Lead Pamphlet – Proteja a su familia contra el plomo en el hogar 
L.  Lake County Consortium Violence Against Women Act Policy and Emergency Transfer Plan 
M. VAWA Notice of Occupancy Rights Template 
N.  VAWA Certification Form Template 
O.  VAWA Emergency Transfer Request Form 
P.  VAWA Lease Addendum  
Q.  Match Report 
R.  TBRA Set Up Form 
 

Lake County Housing Authority

33928 North U.S. Highway 45, Grayslake, IL 60030

Page 1 of 3

2019 Payment Standards

All new contracts with an effective date of November 1, 2019 and re-examinations with the

effective date of January 1, 2020 must use the following payment standards.

Decrease in payment standards: Payment standards highlighted in BOLD decreased. Family’s

residing in these units will not receive a reduction in subsidy. Continue to use the existing higher

payment standard for the family’s subsidy calculation for as long as the family continues to

receive the voucher assistance in that unit (per the Housing Opportunity Through Modernization

Act of 2016 - HOTMA).

**Indicates Choices Area

ZIP 0 BR 1BR 2BR 3BR 4BR 5BR

60002

870

970

1130

1440

1710

1967

** 60010

1390

1570

1820

2310

2750

3163

** 60011

980

1110

1280

1630

1940

2231

** 60013

1100

1230

1430

1820

2160

2484

** 60015

1430

1610

1870

2380

2830

3255

60020

820

920

1070

1360

1620

1863

60021

840

950

1100

1400

1660

1909

** 60030

1020

1150

1330

1690

2010

2312

** 60031

1070

1210

1400

1780

2120

2438

** 60035

1430

1610

1870

2380

2830

3255

** 60040

1030

1160

1340

1700

2030

2335

60041

920

1030

1200

1520

1820

2093

** 60042

1180

1330

1540

1960

2330

2680

** 60044

1210

1360

1580

2010

2390

2749

** 60045

1430

1610

1870

2380

2830

3255

60046

1070

1210

1400

1780

2120

2438

** 60047

1290

1460

1690

2150

2560

2944

** 60048

1090

1220

1420

1800

2150

2473

60050

990

1110

1290

1640

1950

2243

60051

1080

1220

1410

1790

2130

2450

** 60060

1060

1200

1390

1770

2100

2415

** 60061

1200

1350

1570

1990

2370

2726

60064

830

930

1080

1370

1630

1875

Lake County Housing Authority

33928 North U.S. Highway 45, Grayslake, IL 60030

Page 2 of 3

ZIP 0 BR 1BR 2BR 3BR 4BR 5BR

** 60069

1430

1610

1870

2380

2830

3255

60073

1100

1240

1440

1830

2180

2507

** 60074

1000

1130

1310

1660

1980

2277

** 60081

1220

1370

1590

2020

2410

2772

** 60083

1430

1610

1870

2380

2830

3255

60084

970

1090

1260

1600

1910

2197

60085

850

960

1110

1410

1680

1932

60087

910

1030

1190

1510

1800

2070

** 60089

1290

1450

1680

2130

2540

2921

60096

1010

1140

1320

1680

2000

2300

60099

900

1010

1170

1490

1770

2036

Lake County Housing Authority

33928 North U.S. Highway 45, Grayslake, IL 60030

Page 3 of 3

ZIP Primary City Include s Citie s

60002 Antioch

Old Mill Cre ek, Old Mill Crk

** 60010 Barrington

Lake Barrington, North Barrington, Port Barrington,Tower Lakes

** 60011 Barrington

** 60013 Cary

Lake County only

** 60015 Deerfield

Bannockburn, Riverwoods

60020 Fox Lake

Volo

60021 Fox River Grove

Fox River Grove - Lake County only

** 60030 Grayslake

Gages Lake, Hainesville, Third Lake, Wildwood

** 60031 Gurnee

** 60035 Highland Park

** 60040 Highwood

60041 Ingleside

Volo

60042 Island Lake

** 60044 Lake Bluff

** 60045 Lake Forest

Mettawa

60046 Lake Villa

Lindenhurst, Old Mill Cree k, Old Mill Crk

** 60047 Lake Zurich

Hawthorn Wds, Hawthorn Woods, Kildeer, Long Grove

** 60048 Libe rtyville

60050 Mchenry

Lakemoor - Lake County only

60051 Mchenry

Lakemoor, Volo - Lake County only

** 60060 Mundelein

Long Grove

** 60061 Ve rnon Hills

Indian Creek

** 60069 Lincolnshire

P rairie View, P rairie view

60073 Round Lake

Hainesville, Round Lake Beach, Round Lake Heights, Round Lake

Park, Round Lk Bch, Round Lk Hts, Round Lk Park, Volo

** 60074 Palatine

Kildeer - Lake County only

** 60081 Spring Grove

** 60083 Wadsworth

Bea ch P a rk, Old Mill Cre ek, Old Mill Crk

60084 Wauconda

Lake Barrington, Lk Barrington

60085 Waukegan

Park City and Unincorporated Waukegan only

60087 Waukegan

Beach Park and Unincorporated Waukegan only

** 60089 Buffalo Grove

Lake County only

60096 Winthrop Harbor

Winthrop Harbor

60099 Zion

Beach Park

The Housing Authority of the City of North Chicago, Illinois

1440 Jackson St. North Chicago, Illinois 60064

Phone: (847) 785-4300 Fax: (847) 689-4489

2019 Payment Standards

1Bedroom

2 Bedroom

3 Bedroom

4 Bedroom

5 Bedroom

$900

$1,050

$1,340

$1,600

1,840

PLEASE BE ADVISED THAT PAYMENT STANDARDS ARE NOT

RENTAL AMOUNTS!!

Rental Amounts

The North Chicago Housing Authority will perform an affordability test to determine if the proposed

rental amount is affordable.

Landlord Requirements

The City Of North Chicago also requires all landlords to have a landlords’ license. To apply for a license

please contact the City of North Chicago Building Department @ 847-596-8650.

The City Of North Chicago also requires all landlords to have their property inspected by the city building

department before each new tenant.

North Chicago Housing Authority requires copies of both the city inspection and the landlord license

prior to inspecting a unit for a (HCV) Housing Choice Voucher participant.

Before a unit will be inspected we will perform a rent reasonableness test. We are required by The

Department of Housing and Urban Development to show the rent we are approving is comparable to non

subsidized units. We are also required to perform an affordability test.

Please do not hesitate to contact the HCV Department with any questions or concerns you may have with

regards to the program.

RENT REASONABLENESS CHECKLIST AND CERTIFICATION

Proposed Unit

Unit #1

Unit #2

Unit #3

Address

Number of Bedrooms

Square Feet

Type of Unit/Construction

Housing Condition

Location/Accessibility

Amenities

Unit:

Site:

Neighborhood:

Age in Years

Utilities (type)

Unit Rent

Utility Allowance

Gross Rent

Handicap Accessible?

CERTIFICATION:

A. Compliance with Payment Standard

____________________ _____________ __________________

Proposed Contract Rent + Utility Allowance = Proposed Gross Rent

Approved rent does not exceed applicable Payment Standard of

$_____________.

B. Rent Reasonableness

Based upon a comparison with rents for comparable units, I have determined

that the proposed rent for the unit [ ]is [ ] is not reasonable.

Name:

Signature:

Date:

SAMPLE TBRA APPLICATION

APPLICATION FOR RENTAL ASSISTANCE

APPLICANT NAME:

Current Address:

City, State, Zip Code:

Home Phone: Alternate Phone:

HOUSEHOLD COMPOSITION

(List the Head of Household and all other members who will be living in the unit. Give the

relationship of each family member to the head.)

Member's Full Name

Relationship

Birthdate

Age

Sex

Race of Head of Household (Check One) - Optional

(This information is being collected to assure compliance with fair housing and equal opportunity rules.)

White  Black  Asian/Pacific Islander

Native American/Alaskan Native  Hispanic

INCOME INFORMATION

What is the total annual income of all household members? (Include wages, salaries and tips; other

income such as alimony, child support; and Social Security, AFDC or other benefits)

Member's

Full Name

Source of Income

Annual

Amount

Payment Basis

(weekly, monthly, etc.)

ASSET INFORMATION

List the type and source of any family assets. Provide both the current cash value and the

estimated annual income from the asset.

Member's Full Name

Type and Source of Asset

(e.g.bank accounts, investments)

Cash Value

of Asset

Annual

Income from

Asset

EXPENSE INFORMATION

Yes  No Does your household have un-reimbursed medical expenses in excess of 3 percent

of annual income?

Yes  No Does your household pay child care expenses for children under the age of 13 that

enable a family member to work or go to school?

Yes  No Does your household pay care expenses for the care of a family member with

disabilities that enable a family member to work?

APPLICATION CERTIFICATION: I/we understand that the above information is being collected to

determine if I/we are eligible to receive rental assistance. I/we authorize the [Program

Administrator] to verify all information provided on this application.

Head of Household Signature Date

Spouse Signature Date

Previous editions are obsolete Page 1 of 8 form

HUD

52580

(3/2001)

ref Handbook 7420.8

Inspection Checklist

U.S. Department of Housing

OMB Approval No. 2577-0169

and Urban Development

(Exp. 04/30/2014)

Housing Choice Voucher Program Office of Public and Indian Housing

Public reporting burden for this collection of information is estimated to average 0.50 hours per response, including the time for reviewing instructions,

searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not

conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMB control number.

Assurances of confidentiality are not provided under this collection.

This collection of information is authorized under Section 8 of the U.S. Housing Act of l937 (42 U.S.C. 1437f). The information is used to determine

if a unit meets the housing quality standards of the section 8 rental assistance program.

Privacy Act Statement. The Department of Housing and Urban Development (HUD) is authorized to collect the information required on this form by

Section 8 of the U.S. Housing Act of 1937 (42 U.S.C. 1437f). Collection of the name and address of both family and the owner is mandatory. The

information is used to determine if a unit meets the housing quality standards of the Section 8 rental assistance program. HUD may disclose this information

to Federal, State and local agencies when relevant to civil, criminal, or regulatory investigations and prosecutions. It will not be otherwise disclosed or

released outside of HUD, except as permitted or required by law. Failure to provide any of the information may result in delay or rejection of family participation.

Name of Family

Tenant ID Number

Date of Request (mm/dd/yyyy)

Inspector

Neighborhood/Census Tract

Date of Inspection (mm/dd/yyyy)

Type of Inspection

Initial Special Reinspection

Date of Last Inspection (mm/dd/yyyy) PHA

A. General Information

Inspected Unit

Year Constructed (yyyy)

Housing

Type (check as appropriate)

Single Family Detached

Duplex or Two Family

Row House or Town House

Low Rise: 3, 4 Stories,

Including Garden Apartment

High Rise; 5 or More Stories

Manufactured Home

Congregate

Cooperative

Independent Group

Residence

Single Room Occupancy

Shared Housing

Other

Full Address (including Street, City, County, State, Zip)

Number of Children in Family Under 6

Owner

Name of Owner or Agent Authorized to Lease Unit Inspected Phone Number

Address of Owner or Agent

B. Summary Decision On Unit (To be completed after form has been filled out

Pass

Fail

Inconclusive

Number of Bedrooms for Purposes

of the FMR or Payment Standard

Number of Sleeping Rooms

Inspection Checklist

Item

No.

Living Room

Yes

Pass

Fail

Conc.

Comment

Final Approval

Date (mm/dd/yyyy)

1.1 Living Room Present

1.2 Electricity

1.3 Electrical Hazards

1.4 Security

1.5 Window Condition

1.6 Ceiling Condition

1.7 Wall Condition

1.8 Floor Condition

Previous editions are obsolete Page 2 of 8 form

HUD

52580

(3/2001)

ref Handbook 7420.8

* Room Codes: 1 = Bedroom or Any Other Room Used for Sleeping (regardless of type of room); 2 = Dining Room or Dining Area;

3 = Second Living Room, Family Room, Den, Playroom, TV Room; 4 = Entrance Halls, Corridors, Halls, Staircases; 5 = Additional Bathroom; 6 = Other

Item

No.

1. Living Room (Continued)

Yes

Pas

Fail

In-

Conc.

Comment

Final Approval

Date (mm/dd/yyyy)

1.9

Lead-Based Paint

Are all painted surfaces free of deteriorated

paint?

If not, do deteriorated surfaces exceed two

square feet per room and/or is more than

10% of a component?

Not Applicable

2. Kitchen

2.1 Kitchen Area Present

2.2 Electricity

2.3 Electrical Hazards

2.4 Security

2.5 Window Condition

2.6 Ceiling Condition

2.7 Wall Condition

2.8 Floor Condition

2.9

Lead-Based Paint

Are all painted surfaces free of deteriorated

paint?

If not, do deteriorated surfaces exceed two

square feet per room and/or is more than

10% of a component?

Not Applicable

2.10 Stove or Range with Oven

2.11 Refrigerator

2.12 Sink

2.13

Space for Storage, Preparation, and Serving

of Food

3. Bathroom

3.1 Bathroom Present

3.2 Electricity

3.3 Electrical Hazards

3.4 Security

3.5 Window Condition

3.6 Ceiling Condition

3.7 Wall Condition

3.8 Floor Condition

Flush Toilet in Enclosed Room in Unit

3.11 Fixed Wash Basin or Lavatory in Unit

3.12 Tub or Shower in Unit

3.13 Ventilation

Lead-Based Paint

Are all painted surfaces free of deteriorated

paint?

If not, do deteriorated surfaces exceed two

square feet per room and/or is more than

10% of a component?

Not Applicable

3.9

3.10

Item

No.

4. Other Rooms Used For Living and Halls

Comment

Final Approval

Date (mm/dd/yyyy)

Room Code* and

(Circle One) (Circle One)

Room Location Right/Center/Left Front/Center/Rear ____Floor Level

4.2 Electricity/Illumination

4.3 Electrical Hazards

4.4 Security

4.5 Window Condition

4.6 Ceiling Condition

4.7 Wall Condition

4.8 Floor Condition

4.9 Lead

Based Paint

Are all painted surfaces free of deteriorated

paint?

If not, do deteriorated surfaces exceed two

square feet per room and/or is more than

10% of a component?

.10 Smoke Detectors

4.1 Room Code* and (Circle One) (Circle One)

Room Location Right/Center/Left Front/Center/Rear ____Floor Level

4.9 Lead

Based Paint

Are all painted surfaces free of deteriorated

paint?

If not, do deteriorated surfaces exceed two

square feet per room and/or is more than

10% of a component?

4.10 Smoke Detectors

4.1 Room Code* and

Room Location

4.2 Electricity/Illumination

4.3 Electrical Hazards

4.4 Security

4.5 Window Condition

4.6 Ceiling Condition

4.7 Wall Condition

4.8 Floor Condition

4.9 Lead

Based Paint

Are all painted surfaces free of deteriorated

paint?

If not, do deteriorated surfaces exceed two

square feet per room and/or is more than

10% of a component?

In-

Conc.

Yes

Pass

Fail

Right/Center/Left Front/Center/Rear ____Floor Level

(Circle One)

Not Applicable

4.2 Electricity/Illumination

4.3 Electrical Hazards

4.4 Security

4.5 Window Condition

4.6 Ceiling Condition

4.7 Wall Condition

4.8 Floor Condition

Not Applicable

Previous editions are obsolete Page 3 of 8 form HUD52580 (3/2001)

ref Handbook 7420.8

Previous editions are obsolete Page 4 of 8 form

HUD

52580

(3/2001)

ref Handbook 7420.8

Item

No.

4. Other Rooms Used For Living and Halls

Yes

Pass

Fail

In-

Conc.

Comment

Final Approval

Date (mm/dd/yyyy)

4.1

(Circle One) (Circle One)

Right/Center/Left Front/Center/Rear

____Floor Level

RoomLo cation

4.2 Electricity/Illumination

4.3 Electrical Hazards

4.4 Security

4.5 Window Condition

4.6 Ceiling Condition

4.7 Wall Condition

4.8 Floor Condition

4.9

Lead-Based Paint

Are all painted surfaces free of deteriorated

paint?

If not, do deteriorated surfaces exceed two

square feet per room and/or is more than

10% of a component?

Not Applicable

4.10 Smoke Detectors

4.1

Room Code* and (Circle One) (Circle One)

Room Location Right/Center/Left Front/Center/Rear

____Floor Level

4.2 Electricity/Illumination

4.3 Electrical Hazards

4.4 Security

4.5 Window Condition

4.6 Ceiling Condition

4.7 Wall Condition

4.8 Floor Condition

4.9

Lead-Based Paint

Are all painted surfaces free of deteriorated

paint?

If not, do deteriorated surfaces exceed two

square feet per room and/or is more than

10% of a component?

Not Applicable

4.10 Smoke Detectors

5. All Secondary Rooms

(Rooms not used for living)

5.1 None Go to Part 6

5.2 Security

5.3 Electrical Hazards

5.4 Other Potentially Hazardous

Features in these Rooms

Room Code *

and Room Location

Previous editions are obsolete

Page

of 8

form

HUD

52580

(3/2001)

ref Handbook 7420.8

Item 6. Building Exterior

No.

6.1 Condition of Foundation

6.2 Condition of Stairs, Rails, and Porches

6.3 Condition of Roof/Gutters

6.4 Condition of Exterior Surfaces

6.5 Condition of Chimney

6.6

Lead Paint: Exterior Surfaces

Are all painted surfaces free of deteriorated

paint?

If not, do deteriorated surfaces exceed 20

square feet of total exterior surface area?

Not Applicable

6.7 Manufactured Home: Tie Downs

7. Heating and Plumbing

7.1 Adequacy of Heating Equipment

7.2 Safety of Heating Equipment

7.3 Ventilation/Cooling

7.4 Water Heater

7.5 Approvable Water Supply

7.6 Plumbing

7.7 Sewer Connection

8. General Health and Safety

8.4 Garbage and Debris

8.5 Refuse Disposal

8.6 Interior Stairs and Commom Halls

8.7 Other Interior Hazards

8.8 Elevators

8.9 Interior Air Quality

8.10 Site and Neighborhood Conditions

8.11 Lead-Based Paint: Owner's Certification

Not Applicable

If the owner is required to correct any lead-based paint hazards at the property including deteriorated paint or other hazards identified by a

visual assessor, a certified lead-based paint risk assessor, or certified lead-based paint inspector, the PHA must obtain certification that the

work has been done in accordance with all applicable requirements of 24 CFR Part 35. The Lead -Based Paint Owner Certification must be

received by the PHA before the execution of the HAP contract or within the time period stated by the PHA in the owner HQS violation notice.

Receipt of the completed and signed Lead-Based Paint Owner Certification signifies that all HQS lead-based paint requirements have been

met and no re-inspection by the HQS inspector is required.

Comment

Yes

Pass

Fail

In -

Conc.

Final Approval

Date (mm/dd/yyyy)

8.1

Access to Unit

8.2 Fire Exits

8.3 Evidence of Infestation

editions are obsolete

Page

of8

form

HUD

52580

(3/2001)

ref Handbook 7420.8

C. Special Amenities (Optional)

This Section is for optional use of the HA. It is designed to collect additional information about other positive features of the unit that may be present.

Although the features listed below are not included in the Housing Quality Standards, the tenant and HA may wish to take them into consideration in

decisions about renting the unit and the reasonableness of the rent.

Check/list any positive features found in relation to the unit.

D. Questions to ask the Tenant (Optional)

1. Living Room

High quality floors or wall coverings

Working fireplace or stove Balcony,

patio, deck, porch Special windows

or doors

Exceptional size relative to needs of family

Other: (Specify)

4. Bath

Special feature shower head

Built-in heat lamp

Large mirrors

Glass door on shower/tub

Separate dressing room

Double sink or special lavatory

Exceptional size relative to needs of family

Other: (Specify)

2. Kitchen

Dishwasher

Separate freezer

Garbage disposal

Eating counter/breakfast nook

Pantry or abundant shelving or cabinets

Double oven/self cleaning oven, microwave

Double sink

High quality cabinets

Abundant counter-top space

Modern appliance(s)

Exceptional size relative to needs of family

Other: (Specify)

5. Overall Characteristics

Storm windows and doors

Other forms of weatherization (e.g., insulation, weather

stripping) Screen doors or windows

Good upkeep of grounds (i.e., site cleanliness, landscaping,

condition of lawn)

Garage or parking facilities

Driveway

Large yard

Good maintenance of building exterior

Other: (Specify)

3. Other Rooms Used for Living

High quality floors or wall coverings

Working fireplace or stove Balcony,

patio, deck, porch Special windows

or doors

Exceptional size relative to needs of family

Other: (Specify)

6. Disabled Accessibility

Unit is accessible to a particular disability.

Disability

Yes

HOME Lease Addendum (Rev. 8.18.15) Page 1 of 2

HOME LEASE ADDENDUM

Tenant:

Owner:

Unit No. or Address:

Date of Lease:

This HOME Lease Addendum (the Addendum) effective as of the date entered above modifies and is made

part of a Lease between the Tenant and Owner for the housing unit indicated. The Addendum is intended

to ensure compliance with certain requirements of the HOME Investment Partnerships Program

contained within 24 CFR 92.253.

In the event of a discrepancy between the Lease and the HOME Lease Addendum, the provisions of the

Addendum will take precedence.

Section 1. Term of Lease: The HOME Program requires that tenants be offered a lease term of not less

than one (1) year. A tenant may, by mutual agreement with an owner, agree to a shorter lease term.

However, an owner cannot refuse to provide a one (1) year lease or process an application differently

because a prospective tenant has requested a one (1) year lease.

Tenant should check one of the following boxes and initial:

[ ] __________ (initials) The lease term offered by Owner and agreed to by Tenant is for at least

one (1) year.

[ ] __________ (initials) I, the Tenant, understand that the HOME program gives me the right to a

lease of not less than one (1) year and that my application cannot be

rejected for requesting a one (1) year lease. However, I have voluntarily

agreed to a lease term of __________ months.

Section 2. Notice of Rent Increases: Notwithstanding anything to the contrary in the Lease, Owner must

provide not less than 30 days written notice to the Tenant of any increase in rent. Additionally, any rent

increase is subject to all applicable state and local laws.

Section 3. Termination or Refusal to Renew Lease: In no event may the Owner terminate or refuse to

renew the Lease other than for good cause including serious or repeated violations of the Lease. In any

event, the Owner must provide not less than 30 days written notice to the Tenant prior to the termination

or refusal to renew the Lease.

HOME Lease Addendum (Rev. 8.18.15) Page 2 of 2

Section 4. Prohibition Provisions: To the extent that the Lease contains any of the following provisions,

those provisions are null and void:

(1) Any agreement by the Tenant to be sued, to admit guilt, or to a judgment in favor of the Owner

in a lawsuit brought in connection with the Lease;

(2) Any agreement by the Tenant that the Owner may take, hold, or sell personal property of

household members without notice to the Tenant and a court decision on the rights of the parties.

This prohibition, however, does not apply to an agreement by the Tenant concerning disposition

of personal property remaining in the housing unit after the Tenant has moved out of the unit.

The Owner may dispose of this personal property in accordance with State law;

(3) Any agreement by the Tenant not to hold the Owner or the Owner's agents legally responsible for

any action or failure to act, whether intentional or negligent;

(4) Any agreement of the Tenant that the Owner may institute a lawsuit without notice to the Tenant;

(5) Any agreement by the Tenant that the Owner may evict the Tenant or household members

without instituting a civil court proceeding in which the Tenant has the opportunity to present a

defense, or before a court decision on the rights of the parties;

(6) Any agreement by the Tenant to waive any right to a trial by jury;

(7) Any agreement by the Tenant to waive the Tenant's right to appeal, or to otherwise challenge in

court, a court decision in connection with the lease;

(8) Any agreement by the Tenant to pay attorney's fees or other legal costs even if the Tenant wins

in a court proceeding by the Owner against the Tenant. The Tenant, however, may be obligated

to pay costs if the Tenant loses; and

(9) Any agreement by the Tenant to accept supportive services that are offered.

Section 5. Inspections by HOME Participating Jurisdiction and Federal Authorities: In addition to any

other inspection rights in the Lease and subject to any notice provisions within the Lease or required by

applicable state and local laws, the Owner shall have the right to inspect the housing unit and to permit

the HOME Participating Jurisdiction, HUD, HUD’s Office of Inspector General, or the Government

Accountability Office or any of their designees to inspect the unit for the purposes of ensuring compliance

with HOME property standards.

By signing below, this Tenant and Owner (or Owner’s duly authorized representative pursuant to the

terms of the Lease) hereby agree to this HOME Lease Addendum.

Signature of Tenant:

Date:

Signature of Tenant:

Date:

Owner/Owner’s Representative:

Date:

Disclosure of Information on Lead-Based Paint and/or Lead-Based Paint Hazards

Lead Warning Statement

Housing built before 1978 may contain lead-based paint. Lead from paint, paint chips, and dust can pose

health hazards if not managed properly. Lead exposure is especially harmful to young children and pregnant

women. Before renting pre-1978 housing, lessors must disclose the presence of known lead-based paint and/or

lead-based paint hazards in the dwelling. Lessees must also receive a federally approved pamphlet on lead

poisoning prevention.

Lessor’s Disclosure

(a) Presence of lead-based paint and/or lead-based paint hazards (check (i) or (ii) below):

(i) ______ Known lead-based paint and/or lead-based paint hazards are present in the housing

(explain).

_______________________________________________________________________________________

(ii) _____ Lessor has no knowledge of lead-based paint and/or lead-based paint hazards in the

housing.

(b) Records and reports available to the lessor (check (i) or (ii) below):

(i) ______ Lessor has provided the lessee with all available records and reports pertaining to

lead-based paint and/or lead-based paint hazards in the housing (list documents

below).

_______________________________________________________________________________________

(ii) _____ Lessor has no reports or records pertaining to lead-based paint and/or lead-based

paint hazards in the housing.

Lessee’s Acknowledgment (initial)

(d) ________ Lessee has received the pamphlet Protect Your Family from Lead in Your Home.

Agent’s Acknowledgment (initial)

(e) ________ Agent has informed the lessor of the lessor’s obligations under 42 U.S.C. 4852d and

is aware of his/her responsibility to ensure compliance.

Certification of Accuracy

The following parties have reviewed the information above and certify, to the best of their knowledge, that

the information they have provided is true and accurate.

__________________________________________________ __________________________________________________

Lessor Date Lessor Date

__________________________________________________ __________________________________________________

Lessee Date Lessee Date

__________________________________________________ __________________________________________________

Agent Date Agent Date

Declaración de Información sobre Pintura a Base de Plomo y/o Peligros de la Pintura a Base de Plomo

Declaración sobre los Peligros del Plomo

Las viviendas construidas antes del año 1978 pueden contener pintura a base de plomo. El plomo de pintura,

pedazos de pintura y polvo puede representar peligros para la salud si no se maneja apropiadamente.

La exposición al plomo es especialmente dañino para los niños jóvenes y las mujeres embarazadas. Antes de

alquilar (rentar) una vivienda construida antes del año 1978, los arrendadores tienen la obligación de informar

sobre la presencia de pintura a base de plomo o peligros de pintura a base de plomo conocidos en la vivienda.

Los arrendatarios (inquilinos) también deben recibir un folleto aprobado por el Gobierno Federal sobre la

prevención del envenenamiento de plomo.

Declaración del Arrendador

(a) Presencia de pintura a base de plomo y/o peligros de pintura a base de plomo (marque (i) ó (ii) abajo):

(i) ______ Confirmado que hay pintura a base de plomo y/o peligro de pintura a base de plomo en

la vivienda (explique).

_______________________________________________________________________________________

(ii) ______ El arrendador no tiene ningún conocimiento de que haya pintura a base de plomo y/o

peligro de pintura a base de plomo en la vivienda.

(b) Archivos e informes disponibles para el vendedor (marque (i) ó (ii) abajo):

(i) ______ El arrendador le ha proporcionado al comprador todos los archivos e informes disponibles

relacionados con pintura a base de plomo y/o peligro de pintura a base de plomo en la

vivienda (anote los documentos abajo).

_______________________________________________________________________________________

(ii) ______ El arrendador no tiene archivos ni informes relacionados con pintura a base de plomo

y/o peligro de pintura a base de plomo en la vivienda.

Acuse de Recibo del Arrendatario o Inquilino (inicial)

(d) ________ El arrendatario ha recibido el folleto titulado Proteja a Su Familia del Plomo en Su Casa.

Acuse de Recibo del Agente (inicial)

(e) ________ El agente le ha informado al arrendador de las obligaciones del arrendador de acuerdo con

42 U.S.C. 4852(d) y está consciente de su responsabilidad de asegurar su cumplimiento.

Certificación de Exactitud

Las partes siguientes han revisado la información que aparece arriba y certifican que, según su entender,

toda la información que han proporcionado es verdadera y exacta.

__________________________________________________ __________________________________________________

Arrendador Fecha Arrendador Fecha

__________________________________________________ __________________________________________________

Arrendatario Fecha Arrendatario Fecha

__________________________________________________ __________________________________________________

Agente Fecha Agente Fecha

Protect

Your

Family

From

Lead in

Your

Home

United States

Environmental

Protection Agency

United States

Consumer Product

Safety Commission

United States

Department of Housing

and Urban Development

June 2017

Are You Planning to Buy or Rent a Home Built

Before 1978?

Did you know that many homes built before 1978 have lead-based

paint? Lead from paint, chips, and dust can pose serious health

hazards.

Read this entire brochure to learn:

• How lead gets into the body

• How lead aects health

• What you can do to protect your family

• Where to go for more information

Before renting or buying a pre-1978 home or apartment, federal

law requires:

• Sellers must disclose known information on lead-based paint or lead-

based paint hazards before selling a house.

• Real estate sales contracts must include a specic warning statement

about lead-based paint. Buyers have up to 10 days to check for lead.

• Landlords must disclose known information on lead-based paint

and lead-based paint hazards before leases take eect. Leases must

include a specic warning statement about lead-based paint.

If undertaking renovations, repairs, or painting (RRP) projects in

your pre-1978 home or apartment:

• Read EPA’s pamphlet, The Lead-Safe Certied Guide to Renovate Right,

to learn about the lead-safe work practices that contractors are

required to follow when working in your home (see page 12).

Where Lead-Based Paint Is Found

In general, the older your home or childcare facility, the more likely it

has lead-based paint.

Many homes, including private, federally-assisted, federally-

owned housing, and childcare facilities built before 1978 have

lead-based paint. In 1978, the federal government banned consumer

uses of lead-containing paint.

Learn how to determine if paint is lead-based paint on page 7.

Lead can be found:

• In homes and childcare facilities in the city, country, or suburbs,

• In private and public single-family homes and apartments,

• On surfaces inside and outside of the house, and

• In soil around a home. (Soil can pick up lead from exterior paint or

other sources, such as past use of leaded gas in cars.)

Learn more about where lead is found at epa.gov/lead.

“Lead-based paint” is currently dened by the federal government as paint with

lead levels greater than or equal to 1.0 milligram per square centimeter (mg/cm), or

more than 0.5% by weight.

“Lead-containing paint” is currently dened by the federal government as lead in new

dried paint in excess of 90 parts per million (ppm) by weight.

Identifying Lead-Based Paint and Lead-Based Paint

Hazards

Deteriorating lead-based paint (peeling, chipping, chalking,

cracking, or damaged paint) is a hazard and needs immediate

attention. Lead-based paint may also be a hazard when found on

surfaces that children can chew or that get a lot of wear and tear, such

as:

• On windows and window sills

• Doors and door frames

• Stairs, railings, banisters, and porches

Lead-based paint is usually not a hazard if it is in good condition

and if it is not on an impact or friction surface like a window.

Lead dust can form when lead-based paint is scraped, sanded, or

heated. Lead dust also forms when painted surfaces containing

lead bump or rub together. Lead paint chips and dust can get on

surfaces and objects that people touch. Settled lead dust can reenter

the air when the home is vacuumed or swept, or when people walk

through it. EPA currently denes the following levels of lead in dust as

hazardous:

• 40 micrograms per square foot (μg/ft

) and higher for oors,

including carpeted oors

• 250 μg/ft

and higher for interior window sills

Lead in soil can be a hazard when children play in bare soil or when

people bring soil into the house on their shoes. EPA currently denes

the following levels of lead in soil as hazardous:

• 400 parts per million (ppm) and higher in play areas of bare soil

• 1,200 ppm (average) and higher in bare soil in the remainder of the

yard

Remember, lead from paint chips—which you can see—and lead

dust—which you may not be able to see—both can be hazards.

The only way to nd out if paint, dust, or soil lead hazards exist is to

test for them. The next page describes how to do this.

Checking Your Home for Lead

You can get your home tested for lead in several dierent ways:

• A lead-based paint inspection tells you if your home has lead-

based paint and where it is located. It won’t tell you whether your

home currently has lead hazards. A trained and certied testing

professional, called a lead-based paint

inspector, will conduct a paint inspection

using methods, such as:

• Portable x-ray uorescence (XRF) machine

• Lab tests of paint samples

• A risk assessment tells you if your home

currently has any lead hazards from lead

in paint, dust, or soil. It also tells you what

actions to take to address any hazards. A

trained and certied testing professional,

called a risk assessor, will:

• Sample paint that is deteriorated on doors, windows, oors, stairs,

and walls

• Sample dust near painted surfaces and sample bare soil in the

yard

• Get lab tests of paint, dust, and soil samples

• A combination inspection and risk assessment tells you if your home

has any lead-based paint and if your home has any lead hazards, and

where both are located.

Be sure to read the report provided to you after your inspection or risk

assessment is completed, and ask questions about anything you do not

understand.

Checking Your Home for Lead, continued

In preparing for renovation, repair, or painting work in a pre-1978

home, Lead-Safe Certied renovators (see page 12) may:

• Take paint chip samples to determine if lead-based paint is

present in the area planned for renovation and send them to an

EPA-recognized lead lab for analysis. In housing receiving federal

assistance, the person collecting these samples must be a certied

lead-based paint inspector or risk assessor

• Use EPA-recognized tests kits to determine if lead-based paint is

absent (but not in housing receiving federal assistance)

• Presume that lead-based paint is present and use lead-safe work

practices

There are state and federal programs in place to ensure that testing is

done safely, reliably, and eectively. Contact your state or local agency

for more information, visit epa.gov/lead, or call 1-800-424-LEAD

(5323) for a list of contacts in your area.

Hearing- or speech-challenged individuals may access this number through TTY by

calling the Federal Relay Service at 1-800-877-8339.

What You Can Do Now to Protect Your Family

If you suspect that your house has lead-based paint hazards, you

can take some immediate steps to reduce your family’s risk:

• If you rent, notify your landlord of peeling or chipping paint.

• Keep painted surfaces clean and free of dust. Clean oors, window

frames, window sills, and other surfaces weekly. Use a mop or sponge

with warm water and a general all-purpose cleaner. (Remember:

never mix ammonia and bleach products together because they can

form a dangerous gas.)

• Carefully clean up paint chips immediately without creating dust.

• Thoroughly rinse sponges and mop heads often during cleaning of

dirty or dusty areas, and again afterward.

• Wash your hands and your children’s hands often, especially before

they eat and before nap time and bed time.

• Keep play areas clean. Wash bottles, paciers, toys, and stued

animals regularly.

• Keep children from chewing window sills or other painted surfaces, or

eating soil.

• When renovating, repairing, or painting, hire only EPA- or state-

approved Lead-Safe Certied renovation rms (see page 12).

• Clean or remove shoes before entering your home to avoid tracking

in lead from soil.

• Make sure children eat nutritious, low-fat meals high in iron, and

calcium, such as spinach and dairy products. Children with good diets

absorb less lead.

Reducing Lead Hazards

Disturbing lead-based paint or

removing lead improperly can

increase the hazard to your family by

spreading even more lead dust around

the house.

• In addition to day-to-day cleaning

and good nutrition, you can

temporarily reduce lead-based paint

hazards by taking actions, such as

repairing damaged painted surfaces

and planting grass to cover lead-

contaminated soil. These actions are

not permanent solutions and will need

ongoing attention.

• You can minimize exposure to lead

when renovating, repairing, or painting by hiring an EPA- or state-

certied renovator who is trained in the use of lead-safe work

practices. If you are a do-it-yourselfer, learn how to use lead–safe

work practices in your home.

• To remove lead hazards permanently, you should hire a certied lead

abatement contractor. Abatement (or permanent hazard elimination)

methods include removing, sealing, or enclosing lead-based paint

with special materials. Just painting over the hazard with regular

paint is not permanent control.

Always use a certied contractor who is trained to address lead

hazards safely.

• Hire a Lead-Safe Certied rm (see page 12) to perform renovation,

repair, or painting (RRP) projects that disturb painted surfaces.

• To correct lead hazards permanently, hire a certied lead abatement

professional. This will ensure your contractor knows how to work

safely and has the proper equipment to clean up thoroughly.

Certied contractors will employ qualied workers and follow strict

safety rules as set by their state or by the federal government.

Reducing Lead Hazards, continued

If your home has had lead abatement work done or if the housing is

receiving federal assistance, once the work is completed, dust cleanup

activities must be conducted until clearance testing indicates that lead

dust levels are below the following levels:

• 40 micrograms per square foot (μg/ft

) for oors, including carpeted

oors

• 250 μg/ft

for interior windows sills

• 400 μg/ft

for window troughs

For help in locating certied lead abatement professionals in your area,

call your state or local agency (see pages 14 and 15), or visit

epa.gov/lead, or call 1-800-424-LEAD.

Renovating, Repairing or Painting a Home with

Lead-Based Paint

If you hire a contractor to conduct renovation, repair, or painting

(RRP) projects in your pre-1978 home or childcare facility (such as

pre-school and kindergarten), your contractor must:

• Be a Lead-Safe Certied rm approved by EPA or an

EPA-authorized state program

• Use qualied trained individuals (Lead-Safe

Certied renovators) who follow specic lead-safe

work practices to prevent lead contamination

• Provide a copy of EPA’s lead hazard information

document, The Lead-Safe Certied Guide to

Renovate Right

RRP contractors working in pre-1978 homes and childcare facilities

must follow lead-safe work practices that:

• Contain the work area. The area must be contained so that dust and

debris do not escape from the work area. Warning signs must be put

up, and plastic or other impermeable material and tape must be used.

• Avoid renovation methods that generate large amounts of

lead-contaminated dust. Some methods generate so much lead-

contaminated dust that their use is prohibited. They are:

• Open-ame burning or torching

• Sanding, grinding, planing, needle gunning, or blasting with

power tools and equipment not equipped with a shroud and

HEPA vacuum attachment

• Using a heat gun at temperatures greater than 1100°F

• Clean up thoroughly. The work area should be cleaned up daily.

When all the work is done, the area must be cleaned up using special

cleaning methods.

• Dispose of waste properly. Collect and seal waste in a heavy duty

bag or sheeting. When transported, ensure that waste is contained to

prevent release of dust and debris.

To learn more about EPA’s requirements for RRP projects, visit

epa.gov/getleadsafe, or read The Lead-Safe Certied Guide to

Renovate Right.

Other Sources of Lead

Lead in Drinking Water

The most common sources of lead in drinking water are lead pipes,

faucets, and xtures.

Lead pipes are more likely to be found in older cities and homes built

before 1986.

You can’t smell or taste lead in drinking water.

To nd out for certain if you have lead in drinking water, have your

water tested.

Remember older homes with a private well can also have plumbing

materials that contain lead.

Important Steps You Can Take to Reduce Lead in Drinking Water

• Use only cold water for drinking, cooking and making baby formula.

Remember, boiling water does not remove lead from water.

• Before drinking, ush your home’s pipes by running the tap, taking a

shower, doing laundry, or doing a load of dishes.

• Regularly clean your faucet’s screen (also known as an aerator).

• If you use a lter certied to remove lead, don’t forget to read the

directions to learn when to change the cartridge. Using a lter after it

has expired can make it less eective at removing lead.

Contact your water company to determine if the pipe that connects

your home to the water main (called a service line) is made from lead.

Your area’s water company can also provide information about the lead

levels in your system’s drinking water.

For more information about lead in drinking water, please contact

EPA’s Safe Drinking Water Hotline at 1-800-426-4791. If you have other

questions about lead poisoning prevention, call 1-800 424-LEAD.*

Call your local health department or water company to nd out about

testing your water, or visit epa.gov/safewater for EPA’s lead in drinking

water information. Some states or utilities oer programs to pay for

water testing for residents. Contact your state or local water company

to learn more.

* Hearing- or speech-challenged individuals may access this number through TTY

by calling the Federal Relay Service at 1-800-877-8339.

Other Sources of Lead, continued

• Lead smelters or other industries that release lead into the air.

• Your job. If you work with lead, you could bring it home on your body

or clothes. Shower and change clothes before coming home. Launder

your work clothes separately from the rest of your family’s clothes.

• Hobbies that use lead, such as making pottery or stained glass,

or renishing furniture. Call your local health department for

information about hobbies that may use lead.

• Old toys and furniture may have been painted with lead-containing

paint. Older toys and other children’s products may have parts that

contain lead.

• Food and liquids cooked or stored in lead crystal or lead-glazed

pottery or porcelain may contain lead.

• Folk remedies, such as “greta” and “azarcon,” used to treat an upset

stomach.

In 1978, the federal government banned toys, other children’s products, and furniture

with lead-containing paint. In 2008, the federal government banned lead in most

children’s products. The federal government currently bans lead in excess of 100 ppm

by weight in most children’s products.

For More Information

The National Lead Information Center

Learn how to protect children from lead poisoning and get other

information about lead hazards on the Web at epa.gov/lead and

hud.gov/lead, or call 1-800-424-LEAD (5323).

EPA’s Safe Drinking Water Hotline

For information about lead in drinking water, call 1-800-426-4791, or

visit epa.gov/safewater for information about lead in drinking water.

Consumer Product Safety Commission (CPSC) Hotline

For information on lead in toys and other consumer products, or to

report an unsafe consumer product or a product-related injury, call

1-800-638-2772, or visit CPSC’s website at cpsc.gov or

saferproducts.gov.

State and Local Health and Environmental Agencies

Some states, tribes, and cities have their own rules related to lead-

based paint. Check with your local agency to see which laws apply

to you. Most agencies can also provide information on nding a lead

abatement rm in your area, and on possible sources of nancial aid

for reducing lead hazards. Receive up-to-date address and phone

information for your state or local contacts on the Web at epa.gov/lead,

or contact the National Lead Information Center at 1-800-424-LEAD.

Hearing- or speech-challenged individuals may access any of the

phone numbers in this brochure through TTY by calling the toll-

free Federal Relay Service at 1-800-877-8339.

U. S. Environmental Protection Agency (EPA)

Regional Oces

The mission of EPA is to protect human health and the environment.

Your Regional EPA Oce can provide further information regarding

regulations and lead protection programs.

Region 1 (Connecticut, Massachusetts, Maine,

New Hampshire, Rhode Island, Vermont)

Regional Lead Contact

U.S. EPA Region 1

5 Post Oce Square, Suite 100, OES 05-4

Boston, MA 02109-3912

(888) 372-7341

Region 2 (New Jersey, New York, Puerto Rico,

Virgin Islands)

Regional Lead Contact

U.S. EPA Region 2

2890 Woodbridge Avenue

Building 205, Mail Stop 225

Edison, NJ 08837-3679

(732) 321-6671

Region 3 (Delaware, Maryland, Pennsylvania,

Virginia, DC, West Virginia)

Regional Lead Contact

U.S. EPA Region 3

1650 Arch Street

Philadelphia, PA 19103

(215) 814-2088

Region 4 (Alabama, Florida, Georgia,

Kentucky, Mississippi, North Carolina, South

Carolina, Tennessee)

Regional Lead Contact

U.S. EPA Region 4

AFC Tower, 12th Floor, Air, Pesticides & Toxics

61 Forsyth Street, SW

Atlanta, GA 30303

(404) 562-8998

Region 5 (Illinois, Indiana, Michigan,

Minnesota, Ohio, Wisconsin)

Regional Lead Contact

U.S. EPA Region 5 (DT-8J)

77 West Jackson Boulevard

Chicago, IL 60604-3666

(312) 886-7836

Region 6 (Arkansas, Louisiana, New Mexico,

Oklahoma, Texas, and 66 Tribes)

Regional Lead Contact

U.S. EPA Region 6

1445 Ross Avenue, 12th Floor

Dallas, TX 75202-2733

(214) 665-2704

Region 7 (Iowa, Kansas, Missouri, Nebraska)

Regional Lead Contact

U.S. EPA Region 7

11201 Renner Blvd.

WWPD/TOPE

Lenexa, KS 66219

(800) 223-0425

Region 8 (Colorado, Montana, North

Dakota, South Dakota, Utah, Wyoming)

Regional Lead Contact

U.S. EPA Region 8

1595 Wynkoop St.

Denver, CO 80202

(303) 312-6966

Region 9 (Arizona, California, Hawaii,

Nevada)

Regional Lead Contact

U.S. EPA Region 9 (CMD-4-2)

75 Hawthorne Street

San Francisco, CA 94105

(415) 947-4280

Region 10 (Alaska, Idaho, Oregon,

Washington)

Regional Lead Contact

U.S. EPA Region 10

Solid Waste & Toxics Unit (WCM-128)

1200 Sixth Avenue, Suite 900

Seattle, WA 98101

(206) 553-1200

Consumer Product Safety Commission (CPSC)

The CPSC protects the public against unreasonable risk of injury

from consumer products through education, safety standards

activities, and enforcement. Contact CPSC for further information

regarding consumer product safety and regulations.

CPSC

4330 East West Highway

Bethesda, MD 20814-4421

1-800-638-2772

cpsc.gov or saferproducts.gov

U. S. Department of Housing and Urban

Development (HUD)

This document is in the public domain. It may be produced by an individual or organization without

permission. Information provided in this booklet is based upon current scientic and technical

understanding of the issues presented and is reective of the jurisdictional boundaries established by

the statutes governing the co-authoring agencies. Following the advice given will not necessarily

provide complete protection in all situations or against all health hazards that can be caused by lead

exposure.

EPA-747-K-12-001 U. S. EPA Washington DC 20460

U. S. CPSC Bethesda MD 20814

U. S. HUD Washington DC 20410

HUD’s mission is to create strong, sustainable, inclusive

communities and quality aordable homes for all. Contact

HUD’s Oce of Healthy Homes and Lead Hazard Control for

further information regarding the Lead Safe Housing Rule, which

protects families in pre-1978 assisted housing, and for the lead

hazard control and research grant programs.

HUD

451 Seventh Street, SW, Room 8236

Washington, DC 20410-3000

(202) 402-7698

hud.gov/oces/lead/

June 2017

IMPORTANT!

Lead From Paint, Dust, and Soil in and

Around Your Home Can Be Dangerous if

Not Managed Properly

• Children under 6 years old are most at risk for lead

poisoning in your home.

• Lead exposure can harm young children and babies even

before they are born.

• Homes, schools, and child care facilities built before 1978

are likely to contain lead-based paint.

• Even children who seem healthy may have dangerous

levels of lead in their bodies.

• Disturbing surfaces with lead-based paint or removing

lead-based paint improperly can increase the danger to

your family.

• People can get lead into their bodies by breathing or

swallowing lead dust, or by eating soil or paint chips

containing lead.

• People have many options for reducing lead hazards.

Generally, lead-based paint that is in good condition is not

a hazard (see page 10).

Proteja

a su

familia

contra el

plomo

en el

hogar

Agencia de

Protección

Ambiental de los

Estados Unidos (EPA)

Comisión de Seguridad

de Productos del

Consumidor de

Estados Unidos (CPSC)

Departamento

de la Vivienda y de

Desarrollo Urbano de los

Estados Unidos (HUD)

Junio de 2017

¡IMPORTANTE!

El plomo de la pintura, del polvo y de la

tierra en la casa y alrededor de esta puede

ser peligroso si no se maneja adecuadamente

• Los niños menores de 6 años son los que corren mayor

riesgo de envenenamiento por plomo en la casa.

• La exposición al plomo puede hacerle daño a los niños

pequeños y aun a los bebés antes del nacimiento.

• Es probable que las casas, las escuelas y los centros de

cuidado infantil construidos antes de 1978 contengan

pintura con base de plomo.

• Aun los niños que aparentan estar saludables pueden

tener niveles peligrosos de plomo en el cuerpo.

• Alterar las supercies con pintura con base de plomo o

remover incorrectamente la pintura con base de plomo

puede aumentar los peligros para su familia.

• El plomo puede entrar en el cuerpo de las personas al

respirar o tragar polvo de plomo, o al comer tierra o

partículas de pintura que contengan plomo.

• Las personas tienen muchas opciones para reducir los

peligros relacionados con el plomo. Generalmente,

la pintura con base de plomo que está en buenas

condiciones no es peligrosa (vea la página 10).

¿Está planeando comprar o alquilar una casa

construida antes de 1978?

¿Sabía que muchas casas construidas antes de 1978 tienen pintura con

base de plomo? El plomo en la pintura, las partículas y el polvo puede

ser un peligro grave para la salud.

Lea todo este folleto para saber:

• Cómo entra el plomo en el cuerpo.

• Cómo el plomo afecta a la salud.

• Qué puede hacer para proteger a su familia.

• Adónde recurrir para obtener más información.

Antes de alquilar o comprar una casa o un apartamento

construidos antes de 1978, la ley federal requiere lo siguiente:

• Los vendedores tienen que dar la información que posean acerca de

la pintura con base de plomo o los peligros relacionados con dicha

pintura antes de vender una casa.

• Los contratos de venta de inmuebles deben incluir una declaración

de advertencia especíca sobre la pintura con base de plomo. Los

compradores tienen hasta 10 días para vericar la existencia de plomo.

• Los propietarios tienen que dar la información que posean acerca de

la pintura con base de plomo y los peligros relacionados con dicha

pintura antes de que el alquiler entre en vigencia. Los contratos de

alquiler deben incluir una declaración de advertencia especíca sobre

la pintura con base de plomo.

Si emprenderá algún proyecto de renovación, reparación o pintura

(RRP, por sus siglas en inglés) en su casa o apartamento construido

antes de 1978:

• Lea el folleto de la EPA Guía de prácticas acreditas seguras para trabajar

con el plomo para remodeler correctamente.

Comisión de Seguridad de Productos del Consumidor

de Estados Unidos (CPSC)

La CPSC protege al público contra el riesgo irrazonable de daños

causados por productos del consumidor a través de educación,

actividades relacionadas con normas de seguridad y aplicación de la

ley. Comuníquese con la CPSC para obtener más información sobre

los reglamentos y la seguridad de los productos del consumidor.

CPSC

4330 East West Highway

Bethesda, MD 20814-4421

1-800-638-2772

cpsc.gov o saferproducts.gov

Departamento de la Vivienda y de Desarrollo

Urbano de los Estados Unidos (HUD)

Este documento es del dominio público y puede ser reproducido por cualquier persona u organización

sin necesidad de solicitar autorización. La información contenida en este folleto se basa en el conocimiento

cientíco y técnico actual sobre los aspectos presentados, y reeja las barreras jurisdiccionales establecidas por

los estatutos que gobiernan a las agencias que han colaborado en su preparación. Al seguir la asesoría que se

ofrece, no se obtiene necesariamente una protección total para todas las situaciones o contra todos los peligros

para la salud que pueden ser causa de la exposición al plomo.

EPA-747-K-13-001

Junio de 2017

U. S. EPA Washington DC 20460

U. S. CPSC Bethesda MD 20814

U. S. HUD Washington DC 20410

La misión del HUD es crear comunidades fuertes, sustentables

e inclusivas, así como hogares de calidad asequibles para todos.

Comuníquese con la Ocina de Hogares Saludables y Control de

Peligros Relacionados con el Plomo del HUD para obtener más

información acerca de la Regla sobre Viviendas Seguras en relación

con el Plomo, que protege a las familias que residen en viviendas

construidas antes de 1978 que reciben ayuda económica, y acerca de

los programas de control de los peligros relacionados con el plomo y

de subvenciones para investigación.

HUD

451 Seventh Street, SW, Room 8236

Washington, DC 20410-3000

(202) 402-7698

hud.gov/oces/lead/

Medidas sencillas para proteger a su familia

contra los peligros relacionados con el plomo

Si cree que su casa tiene pintura con base de plomo:

• No trate de remover usted mismo la pintura con base de plomo.

• Mantenga siempre las supercies pintadas en buenas

condiciones para minimizar el deterioro.

• Haga que examinen su casa para identicar peligros

relacionados con el plomo. Encuentre un inspector certicado o

un asesor de riesgos en epa.gov/lead.

• Hable con el propietario para que arregle las supercies con

pintura descascarada o picada.

• Limpie con regularidad los pisos, los antepechos de las

ventanas y las demás supercies.

• Tome precauciones para evitar la exposición al polvo de plomo

al remodelar.

• Al realizar renovaciones, reparaciones o pintura, contrate

solamente a empresas de renovación certicadas en prácticas

seguras con el plomo aprobadas por el estado o la EPA.

• Antes de comprar, alquilar o renovar su casa, hágala examinar

para ver si tiene pintura con base de plomo.

• Consulte con su profesional de la salud sobre pruebas para

detectar la presencia de plomo en sus hijos. El pediatra puede

comprobar la presencia de plomo con un simple análisis de

sangre.

• Lave con frecuencia las manos, los biberones, los chupones y

los juguetes de los niños.

• Asegúrese de que los niños coman alimentos saludables, bajos

en grasa, y altos en hierro, calcio y vitamina C.

• Quítese los zapatos o lave la tierra de los zapatos antes de

entrar a su casa.

116

Ocinas regionales de la Agencia de Protección

Ambiental de los Estados Unidos (EPA)

La misión de la EPA es proteger la salud de los seres humanos y el medio

ambiente. La Ocina Regional de la EPA puede darle más información

sobre la normativa y los programas de protección contra el plomo.

Región 1 (Connecticut, Massachusetts, Maine,

New Hampshire, Rhode Island, Vermont)

Regional Lead Contact

(Contacto regional para el plomo)

U.S. EPA Region 1

Suite 1100 (CPT) One Congress Street

Boston, MA 02114-2023

(617) 918-1524

Región 2 (New Jersey, New York, Puerto Rico,

Virgin Islands)

Regional Lead Contact

(Contacto regional para el plomo)

U.S. EPA Region 2

2890 Woodbridge Avenue

Building 205, Mail Stop 225

Edison, NJ 08837-3679

(732) 321-6671

Región 3 (Delaware, Maryland, Pennsylvania,

Virginia, DC, West Virginia)

Regional Lead Contact

(Contacto regional para el plomo)

U.S. EPA Region 3

1650 Arch Street

Philadelphia, PA 19103

(215) 814-2088

Región 4 (Alabama, Florida, Georgia,

Kentucky, Mississippi, North Carolina, South

Carolina, Tennessee)

Regional Lead Contact

(Contacto regional para el plomo)

U.S. EPA Region 4

AFC Tower, 12th Floor, Air, Pesticides & Toxics

61 Forsyth Street, SW

Atlanta, GA 30303

(404) 562-8998

Región 5 (Illinois, Indiana, Michigan,

Minnesota, Ohio, Wisconsin)

Regional Lead Contact

(Contacto regional para el plomo)

U.S. EPA Region 5 (DT-8J)

77 West Jackson Boulevard

Chicago, IL 60604-3666

(312) 886-7836

Región 6 (Arkansas, Louisiana, New Mexico,

Oklahoma, Texas y 66 tribus)

Regional Lead Contact

(Contacto regional para el plomo)

U.S. EPA Region 6

1445 Ross Avenue, 12th Floor

Dallas, TX 75202-2733

(214) 665-2704

Región 7 (Iowa, Kansas, Missouri, Nebraska)

Regional Lead Contact

(Contacto regional para el plomo)

U.S. EPA Region 7

11201 Renner Blvd.

WWPD/TOPE

Lenexa, KS 66219

(800) 223-0425

Región 8 (Colorado, Montana, North

Dakota, South Dakota, Utah, Wyoming)

Regional Lead Contact

(Contacto regional para el plomo)

U.S. EPA Region 8

1595 Wynkoop St.

Denver, CO 80202

(303) 312-6966

Región 9 (Arizona, California, Hawaii,

Nevada)

Regional Lead Contact

(Contacto regional para el plomo)

U.S. EPA Region 9 (CMD-4-2)

75 Hawthorne Street

San Francisco, CA 94105

(415) 947-4280

Región 10 (Alaska, Idaho, Oregon,

Washington)

Regional Lead Contact

(Contacto regional para el plomo)

U.S. EPA Region 10

Solid Waste & Toxics Unit (WCM-128)

1200 Sixth Avenue, Suite 900

Seattle, WA 98101

(206) 553-1200

El plomo entra al cuerpo de muchas maneras

El plomo puede entrar en el cuerpo de adultos y niños si:

• Respiran el polvo de plomo (especialmente durante las actividades

de renovación, reparación y pintura que alteran las supercies

pintadas).

• Tragan polvo de plomo que se ha acumulado en alimentos,

supercies donde se preparan alimentos y otros lugares.

• Comen partículas de pintura o tierra que contengan plomo.

El plomo es especialmente peligroso para los niños menores de

6 años.

• A esta edad, el cerebro y

el sistema nervioso de los

niños son más sensibles a los

efectos dañinos del plomo.

• El cuerpo en crecimiento

de los niños absorbe más

plomo.

• Los bebés y los niños

pequeños se llevan las

manos y otros objetos a

la boca con frecuencia.

Dichos objetos pueden

estar cubiertos de polvo de

plomo.

Las mujeres en edad de concebir deben saber que el plomo es

peligroso para el feto en desarrollo.

• Las mujeres que tienen un nivel alto de plomo en su cuerpo antes del

embarazo o mientras están embarazadas podrían exponer al feto al

plomo a través de la placenta durante su desarrollo.

Para obtener más información

The National Lead Information Center (Centro Nacional de

Información sobre el Plomo)

Averigüe cómo proteger a los niños del envenenamiento por plomo

y obtenga otra información sobre los peligros relacionados con el

plomo por Internet en epa.gov/lead y hud.gov/lead, o llame al

1-800-424-LEAD (5323).

Línea directa de agua potable segura de la EPA

Para obtener información sobre el plomo en el agua potable, llame al

1-800-426-4791 o visite epa.gov/lead para obtener información sobre

el plomo en el agua potable.

Línea directa de la Comisión de Seguridad de Productos del

Consumidor de Estados Unidos (CPSC)

Para pedir información relacionada con el plomo en los juguetes y en

otros productos del consumidor, o para denunciar un producto del

consumidor inseguro o una lesión relacionada con un producto, llame

al 1-800-638-2772, o visite el sitio web de la CPSC en cpsc.gov o

saferproducts.gov.

Agencias del medio ambiente y de salud estatales y locales

Algunos estados, tribus y ciudades tienen sus propias reglas

relacionadas con la pintura con base de plomo. Consulte con su

agencia local para ver cuáles leyes se le aplican. La mayoría de las

agencias también pueden proporcionarle información para encontrar

en su área una empresa para remover el plomo, y para conseguir

posibles fuentes de ayuda económica para la reducción de los peligros

relacionados con el plomo. Obtenga direcciones e información

telefónica actualizadas de contactos locales o estatales por Internet en

epa.gov/lead, o comuníquese con el Centro Nacional de Información

sobre el Plomo llamando al 1-800-424-LEAD.

Las personas con impedimentos auditivos o del habla pueden

acceder a cualquiera de los números de teléfono que se

indican en este folleto a través del sistema TTY llamando en

forma gratuita al Federal Relay Service (Servicio Federal de

Retransmisión) al 1-800-877-8339.

El plomo afecta el cuerpo de muchas maneras. Es importante

saber que aun una exposición a niveles bajos de plomo puede afectar

al niño gravemente.

En los niños, la exposición al plomo

puede causar:

• Daño al sistema nervioso y los riñones.

• Problemas de aprendizaje, desorden

de deciencia de atención y disminución

de la capacidad intelectual.

• Problemas del habla, del lenguaje y

de comportamiento.

• Pobre coordinación muscular.

• Disminución en el crecimiento

muscular y de los huesos.

• Daño en la audición.

Mientras que la exposición a niveles bajos

de plomo es más común, la exposición a niveles

altos de plomo puede causar efectos devastadores en los niños, incluso

convulsiones, pérdida del conocimiento y, en algunos casos, la muerte.

Aunque los niños son especialmente susceptibles a la exposición al

plomo, también puede ser peligroso para los adultos.

En los adultos, la exposición al plomo puede causar:

• Daño a un feto en desarrollo.

• Mayor probabilidad de tener tensión arterial alta durante

el embarazo.

• Problemas de fertilidad (en hombres y mujeres).

• Tensión arterial alta.

• Problemas digestivos.

• Trastornos nerviosos.

• Problemas de memoria y concentración.

• Dolores musculares y articulares.

Efectos del plomo en la salud

Problemas

auditivos

Daño nervioso

en el cerebro

Crecimiento

más lento

Problemas en la

reproducción

(adultos)

Problemas

digestivos

Otras fuentes de plomo (continuación)

• Los hornos de fundición de plomo u otras industrias que emiten

plomo al aire.

• Su trabajo. Si trabaja con plomo, podría traerlo a su casa en el cuerpo

o la ropa. Báñese y cámbiese la ropa antes de volver a su casa. Lave la

ropa de trabajo por separado del resto de la ropa de la familia.

• Los pasatiempos que usan plomo, tales como hacer trabajos

en cerámica, pintar en vidrio o restaurar muebles. Llame al

departamento de salud local para obtener información sobre los

pasatiempos en los que puede usarse plomo.

• Los juguetes y muebles viejos que pueden haberse pintado con

pintura que contenga plomo. Los juguetes viejos y otros productos

para niños pueden contener partes con plomo.

• Los alimentos y líquidos cocinados o almacenados en cristal de

plomo, o en cerámica o porcelana con esmalte de plomo pueden

contener plomo.

• Los remedios caseros, tales como “greta” y “azarcón”, que se usan

para tratar padecimientos estomacales.

En 1978, el gobierno federal prohibió los juguetes, otros productos para niños y los

muebles con pintura que contenga plomo. En 2008, el gobierno federal también

prohibió el plomo en la mayoría de los productos para niños, y actualmente

prohíbe el plomo en cantidades superiores a 100 ppm por peso en la mayoría de los

productos para niños.

Verique el nivel de plomo en su familia

Haga que examinen a sus niños y a su casa si cree que esta tiene

plomo.

El nivel de plomo en la sangre de los niños tiende a aumentar con

rapidez entre los 6 y 12 meses de edad, y tiende a llegar al nivel más

alto entre los 18 y 24 meses de edad.

Consulte a su médico en cuanto a la necesidad de examinar a sus

niños. Un sencillo análisis de sangre puede detectar la presencia de

plomo. Los análisis de sangre para detectar plomo se recomiendan

generalmente para:

• Niños de 1 a 2 años de edad.

• Niños u otros miembros de la familia que hayan estado expuestos a

niveles altos de plomo.

• Niños que deben examinarse en virtud del plan local o estatal de

exámenes médicos.

Su médico puede explicarle los resultados de las pruebas y decirle

si es necesario realizar más análisis.

4 13

Otras fuentes de plomo

Plomo en el agua potable

Las fuentes más comunes de plomo en el agua potable son las tuberías,

grifos y accesorios de plomo.

Las tuberías de plomo son más factibles de encontrar en las ciudades

más antiguas y en las casas construidas antes de 1986.

El plomo en el agua potable no presenta ningún olor ni sabor.

Para saber con seguridad si tiene plomo en el agua potable, debe

hacerla analizar.

Recuerde que las casas más viejas con un pozo privado también

pueden tener materiales de plomería que contengan plomo.

Medidas que puede tomar para reducir el plomo en el agua potable

• Use solo agua fría para beber, cocinar y preparar la leche del bebé.

Recuerde que hervir el agua no elimina el plomo de esta.

• Antes de beber el agua, deje corriendo el grifo para purgar las

tuberías del hogar, tomando una ducha, lave la ropa sucia o lave los

trastes.

• Limpie regularmente el ltro del grifo (también llamado aireador).

• Si usa un ltro certicado para eliminar el plomo, no olvide leer las

instrucciones para aprender cuándo cambiar el cartucho. El uso de

un ltro después de su vencimiento puede hacerlo menos ecaz en la

eliminación del plomo.

Comuníquese con su empresa de suministro de agua para determinar

si la tubería que conecta su casa a la cañería de agua principal (llamada

línea de servicio) es de plomo. Su empresa de agua local también

puede brindarle información sobre los niveles de plomo en el agua

potable de su sistema.

Para obtener más información sobre el plomo en el agua potable,

comuníquese con Línea directa de la EPA sobre el agua potable (en

inglés) al 1-800-426-4791. Si tiene otras preguntas sobre la prevención

del envenenamiento por plomo, llame al 1-800 424-LEAD.*

Llame a su departamento de salud local o a su empresa de agua para

averiguar cómo obtener un análisis del agua de su casa, o visite

epa.gov/safewater para ver información de la EPA sobre el plomo en

el agua potable. Algunos estados o empresas de servicios públicos

ofrecen programas para pagar el análisis del agua de los residentes.

Comuníquese con el servicio público de agua local o estatal para

obtener más información.

Las personas con dicultades del habla o la audición pueden acceder a este número

a través de TTY llamando al Servicio Federal de Transmisión de Información al 1-800-

877-8339.

Dónde se encuentra la pintura con base de plomo

Generalmente, cuanto más vieja sea su casa o centro de cuidado

infantil, mayor será la posibilidad de que tenga pintura con base

de plomo.

Muchas viviendas —incluidas las viviendas privadas, las de

propiedad federal y las que reciben ayuda federal— y centros de

cuidado infantil construidos antes de 1978 tienen pintura con base

de plomo. En 1978, el gobierno federal prohibió el uso por parte del

consumidor de pintura que contenga plomo.

En la página 7, encontrará cómo establecer si la pintura tiene plomo.

El plomo puede encontrarse en:

• Casas y centros de cuidado infantil en la ciudad, el campo o

los suburbios;

• Casas y apartamentos unifamiliares privados y públicos;

• Supercies dentro y fuera de la casa; y

• La tierra alrededor de la casa (la tierra puede acumular plomo de la

pintura exterior u otras fuentes, tales como la gasolina con plomo

que se usaba en el pasado en los automóviles).

Obtenga más información sobre dónde se encuentra plomo en

epa.gov/lead.

En la actualidad, el gobierno federal dene la “pintura con base de plomo” como

pintura con niveles de plomo superiores o iguales a 1.0 miligramo por centímetro

cuadrado (mg/cm) o con más de 0.5% por peso.

En la actualidad, el gobierno federal dene la “pintura que contiene plomo” como

plomo en pintura nueva seca que supere las 90 partes por millón (ppm) por peso.

Renovación, reparación o pintura

Si contrata a un contratista para que realice proyectos de

renovación, reparación o pintura (RRP) en una casa o centro

de cuidado infantil construidos antes de 1978 (como centros

preescolares y jardines de infancia), el contratista debe:

• Ser una empresa certicada en prácticas seguras con el plomo,

aprobada por la EPA o por un programa estatal autorizado por la EPA.

• Utilizar personas cualicadas y capacitadas

(renovadores certicados en prácticas seguras

con el plomo) que empleen prácticas de trabajo

seguras con el plomo especícas, a n de evitar la

contaminación con plomo.

• Darle una copia del documento informativo de la

EPA sobre peligros relacionados con el plomo que

se titula Guía de prácticas acreditas seguras para

trabajar con el plomo para remodeler correctamente.

Los contratistas de RRP que trabajen en casas o

centros de cuidado infantil construidos antes de

1978 deben seguir prácticas de trabajo seguras con el plomo que:

• Contengan el área de trabajo. Debe contenerse el área para que

el polvo y los escombros no se escapen del área de trabajo. Deben

colocarse letreros de advertencia, y debe usarse cinta y material

plástico u otro tipo de material impermeable.

• Eviten los métodos de renovación que generan grandes

cantidades de polvo contaminado con plomo. Algunos métodos

producen tanto polvo contaminado con plomo que su uso está

prohibido. Entre estos métodos se incluyen:

• Quema o ameado a llama abierta.

• Lijado, esmerilado, cepillado, uso de pistolas de aguja o limpieza a

chorro con herramientas eléctricas y equipos sin cubierta y

accesorio de aspiradora HEPA.

• Pistola de aire caliente a temperaturas superiores a 1100 °F.

• Limpien minuciosamente. El área de trabajo debe limpiarse

diariamente. Una vez terminado todo el trabajo, debe limpiarse el

área con métodos de limpieza especiales.

• Eliminen los desechos adecuadamente. Recoja los residuos en una

bolsa o lámina de alta resistencia y séllela. Cuando transporte los

residuos, asegúrese de que la bolsa o lámina esté bien cerrada para

que el polvo y los escombros no se escapen.

Para obtener más información sobre los requisitos de la EPA para los

proyectos de RRP, visite epa.gov/getleadsafe o lea Guía de prácticas

acreditas seguras para trabajar con el plomo para remodeler correctamente.

Identicando la pintura con base de plomo y los

peligros de la pintura con base de plomo

La pintura con base de plomo deteriorada (descascarada, picada,

pulverizada, agrietada o dañada) es un peligro y requiere atención

inmediata. La pintura con base de plomo también puede ser un

peligro si se encuentra en supercies que los niños puedan morder o

que se desgasten mucho, tales como:

• Ventanas y antepechos de ventanas.

• Puertas y marcos de puertas.

• Escaleras, pasamanos, barandas y porches.

La pintura con base de plomo generalmente no es peligrosa si está

en buenas condiciones y no está en una supercie de impacto o de

fricción, como en una ventana.

El polvo de plomo puede formarse al raspar, lijar o calentar la pintura

con base de plomo. También se forma cuando las supercies pintadas

que contienen polvo se golpean o frotan entre sí. Las partículas y

el polvo de la pintura que contiene plomo pueden acumularse en

supercies y objetos que las personas tocan. El polvo de plomo que

se ha acumulado puede volver a mezclarse con el aire cuando se

aspira o barre la casa, o cuando las personas caminan sobre el mismo.

Actualmente, la EPA dene como peligrosos los siguientes niveles de

plomo en el polvo:

• 40 microgramos por pie cuadrado (μg/pie

) o más en pisos, incluidos

pisos alfombrados.

• 250 μg/pie

o más en los antepechos de ventanas interiores.

El plomo en la tierra puede ser peligroso cuando los niños juegan en

tierra descubierta o cuando las personas meten tierra en la casa con

los zapatos. Actualmente, la EPA dene como peligrosos los siguientes

niveles de plomo en la tierra:

• 400 partes por millón (ppm) o más en áreas de juego de tierra

descubierta.

• 1,200 ppm (promedio) o más en la tierra descubierta del resto del

jardín.

Recuerde que el plomo de las partículas de pintura —que puede

ver— y el polvo de plomo —que tal vez no pueda ver— pueden

ser peligrosos.

La única forma de saber si existe peligro debido a la presencia de

plomo en pintura, polvo o tierra es realizando pruebas. En la página

siguiente se describe cómo hacer esto.

6 11

Reduciendo los peligros del plomo (continuación)

Si en su casa se realizó un trabajo para remover el plomo o si se

trata de una vivienda que recibe ayuda federal, una vez que se termine

el trabajo, deben realizarse las actividades de limpieza del polvo hasta

que las pruebas de aprobación indiquen que los niveles de polvo de

plomo están por debajo de los siguientes niveles:

• 40 microgramos por pie cuadrado (μg/pie

) en pisos, incluidos

pisos alfombrados.

• 250 μg/pie

en los antepechos de ventanas interiores.

• 400 μg/pie

en los canales de ventanas.

Para obtener ayuda para localizar en su área profesionales certicados

que remuevan el plomo, llame a la agencia estatal o local (vea las

páginas 14 y 15), visite epa.gov/lead o llame al 1-800-424-LEAD.

Reduciendo los peligros del plomo

Alterar la pintura con base de plomo

o remover incorrectamente el plomo

puede aumentar el peligro para su

familia, ya que esparce aún más el

polvo de plomo en la casa.

• Además de la limpieza diaria y la

buena nutrición, usted puede reducir

temporariamente los riesgos

relacionados con la pintura con base

de plomo tomando medidas, como la

reparación de las supercies pintadas que

estén dañadas y plantar césped para cubrir

la tierra contaminada con plomo. Estas

medidas no son soluciones permanentes y

necesitarán atención continua.

• Para minimizar la exposición al plomo cuando renueve, repare o pinte

su casa, contrate a un renovador certicado por el estado o la EPA que

esté capacitado en el uso de prácticas de trabajo seguras con el plomo.

Si es una persona que suele hacer los trabajos por su cuenta, aprenda a

utilizar prácticas de trabajo seguras con el plomo en su casa.

• Para remover permanentemente los peligros relacionados con

el plomo, debe contratar a un contratista certicado para que

"remueva" el plomo. Los métodos para remover (o eliminar

permanentemente el peligro) incluyen la eliminación, el sellado o

el revestimiento de la pintura con base de plomo con materiales

especiales. Simplemente pintar sobre la pintura que presenta riesgos

con una pintura común no es un control permanente.

Siempre recurra a un contratista certicado que esté capacitado

para corregir los peligros relacionados con el plomo de manera

segura.

• Contrate a una empresa certicada en prácticas seguras con el plomo

(vea la página 12) para realizar proyectos de renovación, reparación o

pintura (RRP) a n de no alterar las supercies pintadas.

• Para corregir permanentemente los peligros relacionados con el

plomo, contrate a un profesional certicado para que "remueva" el

plomo. Esto asegurará que el contratista sepa cómo trabajar en forma

segura y tenga el equipo apropiado para limpiar minuciosamente.

Los contratistas certicados contratarán a trabajadores cualicados

y seguirán reglas estrictas de seguridad según lo dicta el estado o el

gobierno federal.

Vericando si su casa tiene plomo

Puede evaluar su casa de diferentes maneras para determinar si tiene

plomo:

• Una inspección de la pintura con base de plomo le dirá si su casa

tiene pintura con base de plomo y dónde se localiza. Sin embargo,

esta inspección no le dirá si en su casa existen

actualmente peligros relacionados con el

plomo. Un profesional experto en pruebas

capacitado y certicado, que se llama

inspector de pintura con base de plomo,

realizará la inspección de la pintura utilizando

métodos como:

• Máquina portátil de uorescencia por rayos

X (XRF, por sus siglas en inglés).

• Pruebas de laboratorio de muestras de

pintura.

• Una evaluación de riesgo le dirá si en

su casa existe actualmente algún peligro

relacionado con el plomo debido a la presencia de plomo en la pintura,

el polvo o la tierra. También le dirá qué acciones debe llevar a cabo para

eliminar estos peligros. Un profesional experto en pruebas capacitado

y certicado, que se llama asesor de riesgo, hará lo siguiente:

• Tomará muestras de la pintura deteriorada de puertas, ventanas,

pisos, escaleras y paredes.

• Tomará muestras del polvo cerca de las supercies pintadas y

muestras de tierra descubierta del patio.

• Hará pruebas de laboratorio con las muestras de pintura, polvo

y tierra.

• Una combinación de evaluación de riesgo e inspección le dirá si

en su casa hay pintura con base de plomo, si existe algún peligro

relacionado con el plomo y dónde se localizan ambos.

Asegúrese de leer el informe que le entreguen una vez nalizada

la inspección o la evaluación de riesgo, y pregunte todo lo que no

entienda.

Vericando si su casa tiene plomo (continuación)

Al preparar un trabajo de renovación, reparación o pintura en una casa

construida antes de 1978, los renovadores certicados para prácticas

seguras con el plomo (vea la página 12) pueden:

• Tomar muestras de partículas de pintura para determinar si hay

pintura con base de plomo en el área que se prevé renovar y

enviarlas para analizar a un laboratorio especializado en plomo

reconocido por la EPA. En viviendas que reciben ayuda federal, la

persona que recolecte estas muestras debe ser un evaluador de

riesgo o inspector certicado de pintura con base de plomo.

• Utilizar juegos de pruebas reconocidos por la EPA para determinar

si no hay pintura con base de plomo (no se deben usar en viviendas

que reciban ayuda federal).

• Suponer que hay pintura con base de plomo y utilizar prácticas de

trabajo seguras con el plomo.

Existen programas estatales y federales para garantizar que las

pruebas se realicen de modo seguro, conable y con ecacia.

Comuníquese con la agencia estatal o local para obtener más

información, visite epa.gov/lead o llame al 1-800-424-LEAD (5323)

para obtener una lista de contactos en su área.

Las personas con impedimentos auditivos o del habla pueden acceder a este número

a través del sistema TTY llamando al Federal Relay Service (Servicio Federal de

Retransmisión) al 1-800-877-8399.

Lo que usted puede hacer en estos momentos para

proteger a su familia

Si sospecha que su casa tiene algún peligro relacionado con

pintura con base de plomo, puede tomar algunas medidas

inmediatas para reducir el riesgo de su familia:

• Si alquila, infórmele al propietario si hay pintura descascarándose

o picándose.

• Mantenga las supercies pintadas limpias y sin polvo. Limpie

semanalmente los pisos, los marcos y antepechos de las ventanas

y las demás supercies. Use un trapeador o una esponja con agua

tibia y un limpiador para usos múltiples. (Recuerde: nunca mezcle

productos de amoníaco con blanqueadores, ya que pueden formar

gases peligrosos.)

• Limpie inmediatamente y con cuidado las partículas de pintura sin

generar polvo.

• Enjuague bien y con frecuencia las esponjas y las cabezas de los

trapeadores mientras limpia las áreas sucias o con polvo, y vuelva a

hacerlo cuando termine de limpiar.

• Lávese con frecuencia las manos y también las de sus hijos,

especialmente antes de comer, antes de la siesta y antes de irse

a dormir.

• Mantenga limpias las áreas de juego. Lave con regularidad los

biberones, los chupones, los juguetes y los animales de peluche.

• No permita que los niños muerdan los antepechos de las ventanas ni

las demás supercies pintadas, ni tampoco que coman tierra.

• Al realizar renovaciones, reparaciones o pintura, contrate a empresas

de renovación certicadas en prácticas seguras con el plomo

aprobadas por el estado o la EPA (vea la página 12).

• Límpiese o quítese los zapatos antes de entrar a la casa para evitar

meter el plomo de la tierra.

• Asegúrese de que los niños coman alimentos nutritivos, bajos

en grasa y altos en hierro y calcio, tales como las espinacas y los

productos lácteos. Los niños con una dieta adecuada absorben

menos plomo.

Lake County Consortium Violence Against Women Act Policy and Emergency

Transfer Plan

Program Applicability

This Emergency Transfer Plan covers rental beneficiaries and tenants under the following programs:

1. HOME Investment Partnerships Program (“HOME Program”)

2. Community Development Block Grant (“CDBG”)

3. Emergency Solutions Grant (“ESG”)

Background

The 2013 reauthorization of the Violence Against Women Act (“VAWA”) expands housing protections to

all of HUD’s housing programs, as well as provides enhanced protections and options for victims of

domestic violence, dating violence, sexual assault, and stalking. HUD’s Violence Against Women

Reauthorization Act of 2013 Implementation Rule requires Lake County to adopt an emergency transfer

plan no later than June 14, 2017.

This Policy and Plan identifies VAWA protections and limitations, tenants who are eligible for an

emergency transfer, the documentation needed to request an emergency transfer, confidentiality

protections, how an emergency transfer may occur, and guidance to tenants on safety and security. This

plan is based on a model emergency transfer plan published by the U.S. Department of Housing and

Urban Development (HUD), the Federal agency that oversees compliance for the HOME Program and

ESG.

The regulatory basis for and requirements of this Policy and Plan are identified in 24 CFR 5.2005, 2007, &

2009; 24 CFR 91.520; 24 CFR 92.253, 359, 504 & 508; 24 CFR 576.105, 106, 400, 409, & 500.

General VAWA Protections, Requirements, and Limitations

Applicability and Duration

This Policy & Plan applies as follows:

1. HOME Program: all rental projects and all Tenant Based Rental Assistance activities with a

commitment date on or after December 16, 2016. Requirements apply for the entire Period of

Affordability of the project or activity.

2. CDBG: all rental projects and homelessness prevention programs with a contract date on or

after December 16, 2016.

3. ESG: all eligibility and termination decisions that are made with respect to ESG rental assistance

on or after December 16, 2016.

Notice to Applicants and Tenants

All HOME Program, CDBG, and ESG housing providers shall provide to each applicant and tenants the

Notice of Occupancy Rights and the Certification Form (in a form approved by HUD and in accordance

with the applicable requirements of VAWA). The Notice of Occupancy Rights explains the VAWA

protections under 24 CFR Part 5. The Certification Form is to be completed by a tenant in an instance of

domestic violence, dating violence, sexual assault or stalking.

Housing providers must provide the Notice of Occupancy Rights to an applicant or tenant at each of the

following times:

1. At the time the applicant is denied assistance or admission under a covered housing program;

2. At the time the individual is provided assistance or admission under a covered housing program;

3. With any notification of eviction or notification of termination of assistance; and

4. During the 12-month period following December 16, 2016, either during the annual

recertification or lease renewal process, or if there will be no recertification or lease renewal for

a tenant during the 12-month period, through other means.

The Notice of Occupancy and the Certification Form shall be made available in multiple languages, as is

consistent with guidance issued by HUD in accordance with Executive Order 13166 (Improving Access to

Services for Persons with Limited English Proficiency).

Prohibited Basis for Denial or Termination of Assistance or Eviction

An applicant for assistance or tenant assisted under a covered housing program may not be denied

admission to, denied assistance under, terminated from participation in, or evicted from the housing on

the basis or as a direct result of the fact that the applicant or tenant is or has been a victim of domestic

violence, dating violence, sexual assault, or stalking, if the applicant or tenant otherwise qualifies for

admission, assistance, participation, or occupancy. No individual or family may be denied admission to

or removed from an emergency shelter on the basis or as a direct result of the fact that the individual or

family is or has been a victim of domestic violence, dating violence, sexual assault, or stalking, if the

individual or family otherwise qualifies for admission or occupancy.

A tenant in a covered housing program may not be denied tenancy or occupancy rights solely based on

criminal activity directly relating to domestic violence, dating violence, sexual assault, or stalking if:

1. The criminal activity is engaged in by a member of the household of the tenant or any guest or

other person under the control of the tenant, and

2. The tenant or an affiliated individual of the tenant is the victim or threatened victim of such

domestic violence, dating violence, sexual assault or stalking.

Construction of Lease Terms and Terms of Assistance

An incident of actual or threatened domestic violence, dating violence, sexual assault, or stalking shall

not be construed as:

1. A serious or repeated violation of a lease executed under a covered housing program by the

victim or threatened victim of such incident; or

2. Good cause for terminating the assistance, tenancy, or occupancy rights under a covered

housing program of the victim or threatened victim of such incident.

HOME Program Only: All tenants residing in a HOME Program unit or tenants receiving HOME

Program Tenant-Based Rental Assistance shall have a VAWA lease addendum incorporating the

requirements of 24 CFR Parts 5 & 92. Specifically, the lease addendum shall allow the tenant to

terminate the lease without penalty if the conditions for an emergency transfer (below) are met. For

tenants receiving Tenant-Based Rental Assistance, the lease addendum shall require the owner to

notify Lake County before the owner bifurcates the lease, as described below, or provides

notification of eviction to the tenant. If HOME Program Tenant-Based Rental Assistance is the only

assistance provided, the VAWA lease addendum may be written to expire at the end of the rental

assistance period.

ESG Only: Each ESG lease executed on or after December 16, 2016 shall have a VAWA provision or

lease addendum that incorporates all of the requirements of the tenant and owner under the

regulations (24 CFR Parts 5 & 576), the prohibited bases for evictions and restrictions on the

construction of lease terms noted above.

Limitations of VAWA

This policy in no way limits the authority of a covered housing provider to comply with a court order, or

to evict or terminate assistance to a tenant for any violation not premised on an act of domestic

violence, dating violence, sexual assault, or stalking. Additionally, this policy does not limit a housing

provider’s ability to evict or terminate assistance if the housing provider can demonstrate an actual and

imminent threat to other tenants or those employed at or providing service to the property.

Emergency Transfers

In accordance with VAWA, Lake County allows tenants who are victims of domestic violence, dating

violence, sexual assault, or stalking to request an emergency transfer from the tenant’s current unit to

another unit. The ability to request a transfer is available to all tenants, regardless of sex, gender

identity, sexual orientation, race, color, national origin, religion, familial status, disability, or age. The

ability of Lake County to honor such a request for tenants, however, depends upon a preliminary

determination that the tenant is or has been a victim of domestic violence, dating violence, sexual

assault, or stalking, and on whether there is another unit available and is a safe unit for the tenant to

occupy.

Emergency Transfers Eligibility and Priority

A tenant who is a victim of domestic violence, dating violence, sexual assault, or staling, as provided in

HUD’s regulations at 24 CFR Part 5, Subpart L is eligible for an emergency transfer if the tenant expressly

submits a written request for a transfer and reasonably believes that there is a threat of imminent harm

from further violence if the tenant remains in the same unit. If the tenant is a victim of sexual assault,

the tenant may also be eligible to transfer if the sexual assault occurred on the premises within the 90-

calendar-day period preceding a request for an emergency transfer.

Tenants who are not in good standing may still request an emergency transfer if they meet the eligibility

requirements of this plan.

To the extent permitted by local, state and federal law, tenants requesting an emergency transfer under

this Plan shall have priority over other tenants seeking transfers and individuals seeking placement on

waiting lists.

Emergency Transfer Request Documentation

To request an emergency transfer, the tenant shall submit a written request to their landlord. Within

forty-eight (48) hours, the landlord shall notify Lake County of all requests received under this plan. All

notifications to the County shall abide by the confidentiality requirements of this plan.

The tenant’s written request must include the tenant’s name, safe contact information, and one of the

following:

1. A statement expressing that the tenant reasonably believes that there is a threat of imminent

harm from further violence if the tenant were to remain the same dwelling unit; or

2. A statement that the tenant was a sexual assault victim and that the sexual assault occurred on

the premises during the 90-calendar-day period preceding a request for an emergency transfer.

The housing provider may request, in writing, documentation of the incident from the applicant or

tenant. It is at the discretion of the applicant or tenant what documentation to provide. The applicant or

tenant shall have a minimum of 14 days to provide documentation. The housing provider is in no way

required to request documentation. The following are acceptable forms of documentation:

1. The Certification Form; or

2. A document (i) signed by the applicant or tenant, (ii) signed by an employee, agent, or volunteer

of a victim service provider, an attorney, or medical professional, or a mental health

professional from whom the victim has sought assistance relating to domestic violence, dating

violence, sexual assault, or stalking, or the effects of abuse, and (iii) that specifies, under penalty

of perjury, that the professional believes in the occurrence of the incident of domestic violence,

dating violence, sexual assault or stalking that is the ground for protection and remedies under

this subpart, and that the incident meets the applicable definition of domestic violence, dating

violence, sexual assault or stalking under 24 CFR 5.2003.

3. A record of a federal, state, tribal, territorial or local law enforcement agency, court, or

administrative agency; or

4. At statement or other evidence provided by the applicant or tenant

The housing provider may request third-party documentation if conflicting documentation is received

after the original request for documentation. The applicant or tenant shall have 30 days to provide the

documentation in such a situation.

Confidentiality

Lake County and all housing providers shall keep any information submitted, including the fact that an

individual is a victim of domestic violence, dating violence, sexual assault, or stalking, in strict

confidence.

Lake County and all housing providers shall not allow any individual administering assistance on behalf

of the entity, or any persons within their employ, or any individual in the employ of the County or the

housing provider to have access to confidential information unless explicitly authorized for reasons that

call for such individuals to have access to this information under applicable federal, state, or local law.

Lake County and all housing providers will keep confidential any information that the tenant submits in

requesting an emergency transfer, and information about the emergency transfer unless:

1. the tenant gives Lake County or the landlord permission to release the information on a time

limited basis; or

2. disclosure of the information is required by law; or

3. disclosure of the information is required for use in an eviction proceeding or hearing regarding

termination of assistance from the HOME Program, CDBG, or ESG.

This includes keeping confidential the new location of the dwelling unit of the tenant, if one is provided.

Neither Lake County nor any housing provider shall enter confidential information into any shared

database or disclose such information to any other entity or individual, except to the extent the

disclosure fits one of the three exceptions noted above.

A housing provider’s compliance with VAWA protections and confidentiality requirements shall not be

sufficient to constitute evidence of an unreasonable act or omission by the housing provider. Neither

VAWA nor this plan limits a housing provider’s duty to honor court orders about access to or control of

the property; this includes orders issued to protect a victim and orders dividing property among

household members in cases where a household breaks up.

Emergency Transfer Timing and Availability

Neither Lake County nor housing providers can guarantee that a transfer request will be approved or

how long it will take to process a transfer request. Lake County will require housing providers to act as

quickly as possible to move a tenant who is a victim of domestic violence, dating violence, sexual assault,

or stalking to another unit, subject to availability and safety of a unit.

If a tenant reasonably believes a proposed transfer would not be safe, the tenant may request a transfer

to a different unit. If a safe unit is available, the transferred tenant must agree to abide by the terms and

conditions that govern occupancy in the unit to which the tenant has been transferred. The housing

provider may be unable to transfer a tenant to a unit if the tenant has not or cannot establish eligibility

for that unit.

If a housing provider has a safe unit immediately available, the housing provider must allow the tenant

to make an internal emergency transfer. An internal emergency transfer is an emergency relocation of a

tenant to another unit where the tenant would not be categorized as a new applicant; the tenant may

reside in the new unit without having to undergo an application process. A safe unit is a unit that the

tenant requesting the transfer believes is safe.

If a housing provider has no safe units available, the housing provider shall give the tenant priority

above all others when the next unit becomes available. The housing provider shall also notify Lake

County that no internal emergency transfer is available.

If a housing provider has no safe units available for which a tenant who needs an emergency is eligible,

Lake County will assist the tenant in an external emergency transfer by identifying other housing

providers who may have safe units available to which the tenant could move. Lake County will maintain

a list of HOME Program units and make the list available to tenants requesting an emergency transfer.

An external emergency transfer is an emergency relocation of a tenant to another unit where the tenant

would be categorized as a new applicant; the tenant must undergo an application process in order to

reside in the new unit.

Tenants may seek an internal emergency transfer and an external emergency transfer concurrently if a

safe unit is not immediately available.

At the tenant’s request, the housing provider and Lake County will also assist tenants in contacting A

Safe Place and other local organizations aiding victims of domestic violence, dating violence, sexual

assault, or stalking.

ESG Only: If a tenant resides in a project-based rental assistance unit and a safe unit is not immediately

available for an internal emergency transfer, the tenant shall have priority over all other applicants for

tenant-based rental assistance, utility assistance, and units for which project-based rental assistance is

provided. If a household receives tenant-based rental assistance and must separate because of an

emergency transfer and if the non-transferring family members were on the original lease, then they

will continue to receive tenant-based rental assistance. If a household receives tenant-based rental

assistance and must separate because of an emergency transfer and if the non-transferring family

members were not on the original lease, then they may apply for ESG tenant-based rental assistance but

will not receive any priority.

Lease Bifurcation

Housing providers may choose to bifurcate the lease, or remove a household member from a lease in

order to evict or terminate assistance to a household member who engages in criminal activity directly

relating to domestic violence, dating violence, sexual assault, or stalking. Lease bifurcation shall be

carried out in accordance with any requirements or procedures by federal, state, or local law for

termination of assistance or leases, and any requirements under the applicable housing program (HOME

Program, CDBG, or ESG).

If a housing provider chooses to bifurcate a lease, any remaining tenant(s) shall have ninety (90)

calendar days to (i) establish eligibility under the same housing program, (ii) establish eligibility under

another housing program, or (iii) find alternative housing.

HOME Program Only: Following a lease bifurcation, tenants within a HOME Program unit shall be

allowed to remain in that unit and are not subject to the 90-day limitation; similarly, households

receiving HOME Program Tenant-Based Rental Assistance shall continue to receive the rental assistance.

Lake County shall decide if the removed tenant shall continue to receive HOME Program rental

assistance, so long as the removed tenant has not engaged in criminal activity directly relating to

domestic violence, dating violence, sexual assault, or stalking.

ESG Only: Following a lease bifurcation, any tenant-based rental assistance and utility assistance shall

continue for the family member(s) who are not evicted or removed. If the family resides in a unit

receiving project-based rental assistance, the household members who are not evicted or removed can

remain in the unit without interruption to the assistance provided to the unit. The 90-day limitation

does not apply.

Safety and Security of Tenants

Pending processing of the transfer and the actual transfer, if it is approved and occurs, the housing

provider shall inform the tenant of the following resources and urge the tenant to take all reasonable

precautions to be safe.

Tenants who are or have been victims of domestic violence are encouraged to contact the National

Domestic Violence Hotline at 1-800-799-7233 or A Safe Place Hotline at 847-249-4450 for assistance in

creating a safety plan. For persons with hearing impairments, the national hotline can be accessed by

calling 1-800-787-3224 (TTY).

Tenants who have been victims of sexual assault may call the Rape, Abuse & Incest National networks’

national Sexual Assault Hotline at 800-656-HOPE or visit the online hotline at

https://ohl.rainn.org/online/

or they may call the Zacharias Center Hotline at 847-872-7799.

Tenants who are or have been victims of stalking seeking help may visit the National Center for Victims

of Crime’s Stalking Resource Center at

https://wwww.victimsofcrime.org/our-programs/salking-

resource-center.

Recordkeeping and Reporting

Lake County shall keep data on emergency transfers requested under the covered housing programs

and their outcomes. Lake County shall report this data as required by HUD.

LAKE COUNTY TEMPLATE

Notice of Occupancy Rights under the Violence Against Women Act

To all Tenants and Applicants

The Violence Against Women Act (VAWA) provides protections for victims of domestic violence, dating

violence, sexual assault, or stalking. VAWA protections are not only available to women, but are

available equally to all individuals regardless of sex, gender identity, or sexual orientation.

The U.S.

Department of Housing and Urban Development (HUD) is the Federal agency that oversees that Lake

County Consortium is in compliance with VAWA. Housing Providers (HP) receiving funding from Lake

County Consortium must comply with the terms of this Notice of Occupancy Rights. This notice explains

your rights under VAWA. A HUD-approved certification form is attached to this notice. You can fill out

this form to show that you are or have been a victim of domestic violence, dating violence, sexual

assault, or stalking, and that you wish to use your rights under VAWA.”

Protections for Applicants

If you otherwise qualify for assistance under a program funded by Lake County Consortium, you cannot

be denied admission or denied assistance because you are or have been a victim of domestic violence,

dating violence, sexual assault, or stalking.

Protections for Tenants

If you are receiving assistance under a program funded by Lake County Consortium, you may not be

denied assistance, terminated from participation, or be evicted from your rental housing because you

are or have been a victim of domestic violence, dating violence, sexual assault, or stalking.

Also, if you or an affiliated individual of yours is or has been the victim of domestic violence, dating

violence, sexual assault, or stalking by a member of your household or any guest, you may not be denied

rental assistance or occupancy rights under a program funded by Lake County Consortium solely on the

basis of criminal activity directly relating to that domestic violence, dating violence, sexual assault, or

stalking.

Affiliated individual means your spouse, parent, brother, sister, or child, or a person to whom you stand

in the place of a parent or guardian (for example, the affiliated individual is in your care, custody, or

control); or any individual, tenant, or lawful occupant living in your household.

Removing the Abuser or Perpetrator from the Household

HP may divide (bifurcate) your lease in order to evict the individual or terminate the assistance of the

individual who has engaged in criminal activity (the abuser or perpetrator) directly relating to domestic

violence, dating violence, sexual assault, or stalking.

Despite the name of this law, VAWA protection is available regardless of sex, gender identity, or sexual

orientation.

Housing providers cannot discriminate on the basis of any protected characteristic, including race, color, national

origin, religion, sex, familial status, disability, or age. HUD-assisted and HUD-insured housing must be made

available to all otherwise eligible individuals regardless of actual or perceived sexual orientation, gender identity, or

marital status.

If HP chooses to remove the abuser or perpetrator, HP may not take away the rights of eligible tenants

to the unit or otherwise punish the remaining tenants. If the evicted abuser or perpetrator was the sole

tenant to have established eligibility for assistance under the program, HP must allow the tenant who is

or has been a victim and other household members to remain in the unit for a period of time, in order to

establish eligibility under the program or under another HUD housing program covered by VAWA, or,

find alternative housing.

In removing the abuser or perpetrator from the household, HP must follow Federal, State, and local

eviction procedures. In order to divide a lease, HP may, but is not required to, ask you for

documentation or certification of the incidences of domestic violence, dating violence, sexual assault, or

stalking.

Moving to Another Unit

Upon your request, HP may permit you to move to another unit, subject to the availability of other

units, and still keep your assistance. In order to approve a request, HP may ask you to provide

documentation that you are requesting to move because of an incidence of domestic violence, dating

violence, sexual assault, or stalking. If the request is a request for emergency transfer, the housing

provider may ask you to submit a written request or fill out a form where you certify that you meet the

criteria for an emergency transfer under VAWA. The criteria are:

(1) You are a victim of domestic violence, dating violence, sexual assault, or stalking. If

your housing provider does not already have documentation that you are a victim of

domestic violence, dating violence, sexual assault, or stalking, your housing provider may

ask you for such documentation, as described in the documentation section below.

(2) You expressly request the emergency transfer. Your housing provider may choose to

require that you submit a form, or may accept another written or oral request.

(3) You reasonably believe you are threatened with imminent harm from further

violence if you remain in your current unit. This means you have a reason to fear that if

you do not receive a transfer you would suffer violence in the very near future.

You are a victim of sexual assault and the assault occurred on the premises during the

90-calendar-day period before you request a transfer. If you are a victim of sexual

assault, then in addition to qualifying for an emergency transfer because you reasonably

believe you are threatened with imminent harm from further violence if you remain in

your unit, you may qualify for an emergency transfer if the sexual assault occurred on the

premises of the property from which you are seeking your transfer, and that assault

happened within the 90-calendar-day period before you expressly request the transfer.

HP will keep confidential requests for emergency transfers by victims of domestic violence, dating

violence, sexual assault, or stalking, and the location of any move by such victims and their families.

HP’s emergency transfer plan provides further information on emergency transfers, and HP must make a

copy of its emergency transfer plan available to you if you ask to see it.

Documenting You Are or Have Been a Victim of Domestic Violence, Dating Violence, Sexual Assault or

Stalking

HP can, but is not required to, ask you to provide documentation to “certify” that you are or have been a

victim of domestic violence, dating violence, sexual assault, or stalking. Such request from HP must be

in writing, and HP must give you at least 14 business days (Saturdays, Sundays, and Federal holidays do

not count) from the day you receive the request to provide the documentation. HP may, but does not

have to, extend the deadline for the submission of documentation upon your request.

You can provide one of the following to HP as documentation. It is your choice which of the following to

submit if HP asks you to provide documentation that you are or have been a victim of domestic violence,

dating violence, sexual assault, or stalking.

• A complete HUD-approved certification form given to you by HP with this notice, that

documents an incident of domestic violence, dating violence, sexual assault, or stalking. The

form will ask for your name, the date, time, and location of the incident of domestic violence,

dating violence, sexual assault, or stalking, and a description of the incident. The certification

form provides for including the name of the abuser or perpetrator if the name of the abuser or

perpetrator is known and is safe to provide.

• A record of a Federal, State, tribal, territorial, or local law enforcement agency, court, or

administrative agency that documents the incident of domestic violence, dating violence, sexual

assault, or stalking. Examples of such records include police reports, protective orders, and

restraining orders, among others.

• A statement, which you must sign, along with the signature of an employee, agent, or volunteer

of a victim service provider, an attorney, a medical professional or a mental health professional

(collectively, “professional”) from whom you sought assistance in addressing domestic violence,

dating violence, sexual assault, or stalking, or the effects of abuse, and with the professional

selected by you attesting under penalty of perjury that he or she believes that the incident or

incidents of domestic violence, dating violence, sexual assault, or stalking are grounds for

protection.

• Any other statement or evidence that HP has agreed to accept.

If you fail or refuse to provide one of these documents within the 14 business days, HP does not have to

provide you with the protections contained in this notice.

If HP receives conflicting evidence that an incident of domestic violence, dating violence, sexual assault,

or stalking has been committed (such as certification forms from two or more members of a household

each claiming to be a victim and naming one or more of the other petitioning household members as

the abuser or perpetrator), HP has the right to request that you provide third-party documentation

within thirty 30 calendar days in order to resolve the conflict. If you fail or refuse to provide third-party

documentation where there is conflicting evidence, HP does not have to provide you with the

protections contained in this notice.

Confidentiality

HP must keep confidential any information you provide related to the exercise of your rights under

VAWA, including the fact that you are exercising your rights under VAWA.

HP must not allow any individual administering assistance or other services on behalf of HP (for

example, employees and contractors) to have access to confidential information unless for reasons that

specifically call for these individuals to have access to this information under applicable Federal, State,

or local law.

HP must not enter your information into any shared database or disclose your information to any other

entity or individual. HP, however, may disclose the information provided if:

• You give written permission to HP to release the information on a time limited basis.

• HP needs to use the information in an eviction or termination proceeding, such as to evict your

abuser or perpetrator or terminate your abuser or perpetrator from assistance under this

program.

• A law requires HP or your landlord to release the information.

VAWA does not limit HP’s duty to honor court orders about access to or control of the property. This

includes orders issued to protect a victim and orders dividing property among household members in

cases where a family breaks up.

Reasons a Tenant Eligible for Occupancy Rights under VAWA May Be Evicted or Assistance May Be

Terminated

You can be evicted and your assistance can be terminated for serious or repeated lease violations that

are not related to domestic violence, dating violence, sexual assault, or stalking committed against you.

However, HP cannot hold tenants who have been victims of domestic violence, dating violence, sexual

assault, or stalking to a more demanding set of rules than it applies to tenants who have not been

victims of domestic violence, dating violence, sexual assault, or stalking.

The protections described in this notice might not apply, and you could be evicted and your assistance

terminated, if HP can demonstrate that not evicting you or terminating your assistance would present a

real physical danger that:

1) Would occur within an immediate time frame, and

2) Could result in death or serious bodily harm to other tenants or those who work on the property.

If HP can demonstrate the above, HP should only terminate your assistance or evict you if there are no

other actions that could be taken to reduce or eliminate the threat.

Other Laws

VAWA does not replace any Federal, State, or local law that provides greater protection for victims of

domestic violence, dating violence, sexual assault, or stalking. You may be entitled to additional housing

protections for victims of domestic violence, dating violence, sexual assault, or stalking under other

Federal laws, as well as under State and local laws.

Non-Compliance with The Requirements of This Notice

You may report a covered housing provider’s violations of these rights and seek additional assistance, if

needed, by contacting or filing a complaint with:

The U.S. Department of Housing and Urban Development

Chicago Regional Office

Ralph Metcalfe Federal Building

77 West Jackson Boulevard

Chicago, IL 60604

Phone: (312) 353-5680

Fax: (312) 913-8293

TTY: (312) 353-7143

For Additional Information

You may view a copy of HUD’s final VAWA rule at

https://www.federalregister.gov/documents/2016/11/16/2016-25888/violence-against-women-

reauthorization-act-of-2013-implementation-in-hud-housing-programs.

Additionally, HP must make a copy of HUD’s VAWA regulations available to you if you ask to see them.

For questions regarding VAWA, please contact Lake County Community Development at

CommunityDevelopment@lakecountyil.gov.

For help regarding an abusive relationship, you may call the National Domestic Violence Hotline at 1-

800-799-7233 or, for persons with hearing impairments, 1-800-787-3224 (TTY). You may also contact A

Safe Place’s 24-hour hotline at 1-800-600-SAFE (7233) or Zacharias Sexual Abuse Center’s 24-hour

support line at (847) 872-7799.

For tenants who are or have been victims of stalking seeking help may visit the National Center for

Victims of Crime’s Stalking Resource Center at https://www.victimsofcrime.org/our-programs/stalking-

resource-center.

For help regarding sexual assault, you may contact the National Sexual Assault Hotline at (800) 656-

HOPE (4673), or A Safe Place’s 24-hour hotline at 1-800-600-SAFE (7233) or Zacharias Sexual Abuse

Center’s 24-hour support line at (847) 872-7799.

Victims of stalking seeking help may contact A Safe Place’s 24-hour hotline at 1-800-600-SAFE (7233) or

Zacharias Sexual Abuse Center’s 24-hour support line at (847) 872-7799.

Attachment: Certification form HUD-5382

This document was created from Form HUD-5380 (12/2016) template provided by the U.S. Department

of Housing and Urban Development, OMB Approval No. 2577-0286 Expires 06/30/2017.

Form HUD-5382

(12/2016)

CERTIFICATION OF U.S. Department of Housing OMB Approval No. 2577-0286

DOMESTIC VIOLENCE, and Urban Development Exp. 06/30/2017

DATING VIOLENCE,

SEXUAL ASSAULT, OR STALKING,

AND ALTERNATE DOCUMENTATION

Purpose of Form: The Violence Against Women Act (“VAWA”) protects applicants, tenants, and

program participants in certain HUD programs from being evicted, denied housing assistance, or

terminated from housing assistance based on acts of domestic violence, dating violence, sexual assault, or

stalking against them. Despite the name of this law, VAWA protection is available to victims of domestic

violence, dating violence, sexual assault, and stalking, regardless of sex, gender identity, or sexual

orientation.

Use of This Optional Form: If you are seeking VAWA protections from your housing provider, your

housing provider may give you a written request that asks you to submit documentation about the incident

or incidents of domestic violence, dating violence, sexual assault, or stalking.

In response to this request, you or someone on your behalf may complete this optional form and submit it

to your housing provider, or you may submit one of the following types of third-party documentation:

(1) A document signed by you and an employee, agent, or volunteer of a victim service provider, an

attorney, or medical professional, or a mental health professional (collectively, “professional”) from

whom you have sought assistance relating to domestic violence, dating violence, sexual assault, or

stalking, or the effects of abuse. The document must specify, under penalty of perjury, that the

professional believes the incident or incidents of domestic violence, dating violence, sexual assault, or

stalking occurred and meet the definition of “domestic violence,” “dating violence,” “sexual assault,” or

“stalking” in HUD’s regulations at 24 CFR 5.2003.

(2) A record of a Federal, State, tribal, territorial or local law enforcement agency, court, or

administrative agency; or

(3) At the discretion of the housing provider, a statement or other evidence provided by the applicant or

tenant.

Submission of Documentation: The time period to submit documentation is 14 business days from the

date that you receive a written request from your housing provider asking that you provide documentation

of the occurrence of domestic violence, dating violence, sexual assault, or stalking. Your housing

provider may, but is not required to, extend the time period to submit the documentation, if you request an

extension of the time period. If the requested information is not received within 14 business days of when

you received the request for the documentation, or any extension of the date provided by your housing

provider, your housing provider does not need to grant you any of the VAWA protections. Distribution or

issuance of this form does not serve as a written request for certification.

Confidentiality: All information provided to your housing provider concerning the incident(s) of

domestic violence, dating violence, sexual assault, or stalking shall be kept confidential and such details

shall not be entered into any shared database. Employees of your housing provider are not to have access

to these details unless to grant or deny VAWA protections to you, and such employees may not disclose

this information to any other entity or individual, except to the extent that disclosure is: (i) consented to

by you in writing in a time-limited release; (ii) required for use in an eviction proceeding or hearing

regarding termination of assistance; or (iii) otherwise required by applicable law.

Form HUD-5382

(12/2016)

TO BE COMPLETED BY OR ON BEHALF OF THE VICTIM OF DOMESTIC VIOLENCE,

DATING VIOLENCE, SEXUAL ASSAULT, OR STALKING

1. Date the written request is received by victim: _________________________________________

2. Name of victim: ___________________________________________________________________

3. Your name (if different from victim’s):________________________________________________

4. Name(s) of other family member(s) listed on the lease:___________________________________

___________________________________________________________________________________

5. Residence of victim: ________________________________________________________________

6. Name of the accused perpetrator (if known and can be safely disclosed):____________________

__________________________________________________________________________________

7. Relationship of the accused perpetrator to the victim:___________________________________

8. Date(s) and times(s) of incident(s) (if known):___________________________________________

_________________________________________________________________

10. Location of incident(s):_____________________________________________________________

This is to certify that the information provided on this form is true and correct to the best of my knowledge

and recollection, and that the individual named above in Item 2 is or has been a victim of domestic violence,

dating violence, sexual assault, or stalking. I acknowledge that submission of false information could

jeopardize program eligibility and could be the basis for denial of admission, termination of assistance, or

eviction.

Signature __________________________________Signed on (Date) ___________________________

Public Reporting Burden: The public reporting burden for this collection of information is estimated to

average 1 hour per response. This includes the time for collecting, reviewing, and reporting the data. The

information provided is to be used by the housing provider to request certification that the applicant or

tenant is a victim of domestic violence, dating violence, sexual assault, or stalking. The information is

subject to the confidentiality requirements of VAWA. This agency may not collect this information, and

you are not required to complete this form, unless it displays a currently valid Office of Management and

Budget control number.

In your own words, briefly describe the incident(s):

______________________________________________________________________________________

_____________________________________________________________________________

Form HUD-5383

(12/2016)

EMERGENCY TRANSFER U.S. Department of Housing OMB Approval No. 2577-0286

REQUEST FOR CERTAIN and Urban Development Exp. 06/30/2017

VICTIMS OF DOMESTIC

VIOLENCE, DATING VIOLENCE,

SEXUAL ASSAULT, OR STALKING

Purpose of Form: If you are a victim of domestic violence, dating violence, sexual assault, or stalking,

and you are seeking an emergency transfer, you may use this form to request an emergency transfer and

certify that you meet the requirements of eligibility for an emergency transfer under the Violence Against

Women Act (VAWA). Although the statutory name references women, VAWA rights and protections

apply to all victims of domestic violence, dating violence, sexual assault or stalking. Using this form does

not necessarily mean that you will receive an emergency transfer. See your housing provider’s

emergency transfer plan for more information about the availability of emergency transfers.

The requirements you must meet are:

(1) You are a victim of domestic violence, dating violence, sexual assault, or stalking.

If your housing provider does not already have documentation that you are a victim of

domestic violence, dating violence, sexual assault, or stalking, your housing provider may

ask you for such documentation. In response, you may submit Form HUD-5382, or any

one of the other types of documentation listed on that Form.

(2) You expressly request the emergency transfer. Submission of this form confirms

that you have expressly requested a transfer. Your housing provider may choose to require

that you submit this form, or may accept another written or oral request. Please see your

housing provider’s emergency transfer plan for more details.

(3) You reasonably believe you are threatened with imminent harm from further

violence if you remain in your current unit. This means you have a reason to fear that

if you do not receive a transfer you would suffer violence in the very near future.

You are a victim of sexual assault and the assault occurred on the premises during

the 90-calendar-day period before you request a transfer. If you are a victim of sexual

assault, then in addition to qualifying for an emergency transfer because you reasonably

believe you are threatened with imminent harm from further violence if you remain in your

unit, you may qualify for an emergency transfer if the sexual assault occurred on the

premises of the property from which you are seeking your transfer, and that assault

happened within the 90-calendar-day period before you submit this form or otherwise

expressly request the transfer.

Submission of Documentation: If you have third-party documentation that demonstrates why you are

eligible for an emergency transfer, you should submit that documentation to your housing provider if it is

safe for you to do so. Examples of third party documentation include, but are not limited to: a letter or

other documentation from a victim service provider, social worker, legal assistance provider, pastoral

counselor, mental health provider, or other professional from whom you have sought assistance; a current

restraining order; a recent court order or other court records; a law enforcement report or records;

communication records from the perpetrator of the violence or family members or friends of the

perpetrator of the violence, including emails, voicemails, text messages, and social media posts.

Form HUD-5383

(12/2016)

Confidentiality: All information provided to your housing provider concerning the incident(s) of

domestic violence, dating violence, sexual assault, or stalking, and concerning your request for an

emergency transfer shall be kept confidential. Such details shall not be entered into any shared database.

Employees of your housing provider are not to have access to these details unless to grant or deny VAWA

protections or an emergency transfer to you. Such employees may not disclose this information to any

other entity or individual, except to the extent that disclosure is: (i) consented to by you in writing in a

time-limited release; (ii) required for use in an eviction proceeding or hearing regarding termination of

assistance; or (iii) otherwise required by applicable law.

TO BE COMPLETED BY OR ON BEHALF OF THE PERSON REQUESTING A TRANSFER

1. Name of victim requesting an emergency transfer: ______________________________________

2. Your name (if different from victim’s)_________________________________________________

3. Name(s) of other family member(s) listed on the lease:____________________________________

____________________________________________________________________________________

4. Name(s) of other family member(s) who would transfer with the victim:____________________

____________________________________________________________________________________

5. Address of location from which the victim seeks to transfer: _______________________________________

6. Address or phone number for contacting the victim:____________________________________

7. Name of the accused perpetrator (if known and can be safely disclosed):___________________

8. Relationship of the accused perpetrator to the victim:___________________________________

9. Date(s), Time(s) and location(s) of incident(s):___________________________________________

_____________________________________________________________________________________

10. Is the person requesting the transfer a victim of a sexual assault that occurred in the past 90

days on the premises of the property from which the victim is seeking a transfer? If yes, skip

question 11. If no, fill out question 11. ______________

11. Describe why the victim believes they are threatened with imminent harm from further

violence if they remain in their current unit.

_____________________________________________________________________________________

12. If voluntarily provided, list any third-party documentation you are providing along with this

notice: ___________________________________________________________________

This is to certify that the information provided on this form is true and correct to the best of my knowledge,

and that the individual named above in Item 1 meets the requirement laid out on this form for an emergency

transfer. I acknowledge that submission of false information could jeopardize program eligibility and could

be the basis for denial of admission, termination of assistance, or eviction.

Signature __________________________________Signed on (Date) ___________________________

Based on Form HUD-91066

VAWA LEASE ADDENDUM

VIOLENCE AGAINST WOMEN REAUTHORIZATION ACT OF 2013

TENANT

LANDLORD

UNIT NO. & ADDRESS

This Lease Addendum adds the following paragraphs to the Lease between the above-referenced Tenant

and Landlord.

1. Purpose of the Addendum

The Lease for the above referenced unit is being amended to include the provisions of the Violence Against

Women Reauthorization Act of 2013 (VAWA).

2. Conflicts with Other Provisions of the Lease

In case of any conflict between the provisions of this Addendum and other sections of the Lease, the

provisions of this Addendum shall prevail.

3. Effective Date; Term of the Lease Addendum

The effective date of this Lease Addendum is . This Lease Addendum shall continue to be in effect

until the Lease is terminated.

4. VAWA Protections

A. The Landlord may not consider incidents of domestic violence, dating violence, sexual assault or

stalking as serious or repeated violations of the lease or other “good cause” for termination of

assistance, tenancy or occupancy rights of the victim of abuse.

B. The Tenant may terminate this Lease without penalty if __________ (“Provider”) determines that

the Tenant has met the conditions for an emergency transfer under 24 CFR Part 5.2005(e). This

will be evidenced, in part, through the Certification of Domestic Violence, Dating Violence, Sexual

Assault, or Stalking, and Alternate Documentation (HUD Form 5382) and Emergency Transfer

Request for Certain Victims of Domestic Violence, Dating Violence, Sexual Assault, or Stalking

(HUD Form 5383) forms.

C. The Landlord may bifurcate the Lease, or remove a house member from this Lease in order to evict,

remove, terminate occupancy rights, or terminate assistance to such member who engages in

criminal activity directly relating to domestic violence, dating violence, sexual assault, or stalking

against an affiliated individual or other individual without regard to whether the household member

is a signatory to the lease and without evicting, removing, or terminating assistance to a victim of

such criminal activity who is also a tenant or lawful occupant. The Landlord and property owner

may choose to bifurcate the lease at their discretion. The Landlord’s refusal to bifurcate the Lease

does not restrict the Tenant’s ability to terminate this Lease if the Tenant has met the conditions for

an emergency transfer. When HOME tenant-based rental assistance is provided, the owner must

notify Lake County before the owner bifurcates the lease or provides notification of eviction to the

tenant.

D. The Landlord may not consider criminal activity directly relating to abuse, engaged in by a member

of a tenant’s household or any guest or other person under the tenant’s control, cause for termination

Based on Form HUD-91066

Updated 1/13/2020

of assistance, tenancy, or occupancy rights if the tenant or an affiliated individual of the tenant is

the victim or threatened victim of that abuse.

E. The Landlord may request in writing that the victim or an affiliated individual of the tenant certify

that the individual is a victim of abuse and that the tenant complete and submit documentation of

abuse, using the Certification of Domestic Violence, Dating Violence, Sexual Assault or Stalking

(HUD Form 5382), or other documentation as noted on the certification form, to receive protection

under the VAWA. Failure to provide the documentation within 14 business days of request, or an

agreed upon extension date, may result in eviction.

F. Any information submitted to the Landlord will be kept confidential and will not be disclosed to

any other individual or entity except if disclosure is consented to by the victim, is required for an

eviction or is otherwise required by law.

Tenant (head of household) Date

_________________________________________

Landlord Date

Lake County Consortium Housing Fund

Match Report

Developer Name:

Quarter End Date:

Project Address:

Grant Number:

Source of Match Funds

Date of Match

Contribution

Amount of Match

Contribution

If Match is in the Form of a Loan, Please Provide:

Interest Rate Term

Name of Person Completing This Form

Email Address

Phone Number

Signature & Date

Page 1 of 4 Revised (8/06)

Tenant Based Rental Assistance (TBRA) Set Up Form

HOME Program

Check the appropriate box:

Original Submission Change Owner’s Address

Revision

Name and Phone Number of Person Completing Form:

A. General and Activity Information.

Set Up Activity

B. Objective and Outcome.

C. Household Characteristics.

(Refer to code below where applicable) Assisting more than 8 tenants? Make copies of this page for

additional space.

Monthly Rent

Household

Tenant Contract

Last

Name

# of

Bdrms

Sec

Dep

Tenant

Monthly

Rent

TBRA

Monthly

Rent

Total

Monthly

Rent

Med

Hispanic?

Y/N

Race Size Type Paid To

O=Owner

T=Tenant

New?

Y/N

Months

(1 to 24)

D. Total/Subtotal of HOME Funds Requested: $

1. Name of Participant:

2. County Code:

3. IDIS Activity ID Number:

4. Activity Name:

1. Objective (enter code): ___________

(1) Create suitable living environment

(2) Provide decent affordable housing

(3) Create economic opportunities

2. Outcome (enter code): _____________

(1) Availability/accessibility

(2) Affordability

(3) Sustainability

U.S. Department of Housing and Urban Development

Office of Community Planning and Development

Page 2 of 4 Revised (8/06)

E. TBRA Units

Number of TBRA Units:

Designated for the homeless: ________

Of those the number designated for the chronically homeless: __________

Was this activity carried out by a

Faith-based organization (Y/N)? ________

# of Bdrms

0 – SRO/Efficiency

1 – 1 bedroom

2 – 2 bedrooms

3 – 3 bedrooms

4 – 4 bedrooms

5 – 5 or more bedrooms

Household % of Med

1 – 0 to 30%

2 – 30+ to 50%

3 – 50+ to 60%

4 – 60+ to 80%

Household Race

11 – White

12 – Black/African American

13 – Asian

14 – American Indian/Alaska Native

15 – Native Hawaiian/Other Pacific Islander

16 – American Indian/Alaska Native & White

17 – Asian & White

18 – Black/African American & White

19 – American Indian/Alaska Native & Black/African American

–

Other multi-racial

Household Size

1 – 1 person

2 – 2 persons

3 – 3 persons

4 – 4 persons

5 – 5 persons

6 – 6 persons

7 – 7 persons

8 – 8 or more persons

Household Type

1 – Single, non-

elderly

2 – Elderly

3 – Single parent

4 – Two parents

5 – Other

Page 3 of 4 Revised (8/06)

Instructions for Completing the Tenant-Based Rental Assistance Set-up Report

HOME Program

Read the instructions for each item carefully before completing the form.

Applicability. The purpose of this report is to assist with the collection

of information to be entered into IDIS. This report is to be completed for

each TBRA activity set-up in IDIS. A single activity may include up to

99 tenants. For centralized State projects, the tenants must be in the

same county.

Timing. Data is to be entered into IDIS before funds may be drawn

down for the activity. An amended set-up report should be completed to

increase or decrease HOME funding for the activity.

A. General and Activity Information

1. Name of Participant. Enter the name of the participating

jurisdiction or the agency administering the TBRA activity.

2. County Code. Enter the county code of the agency administering

this HOME activity.

3. IDIS Activity ID Number. Enter the activity number assigned by

IDIS.

4. Activity Name. Enter the name designated to the activity. The

blank boxes may be used for internal tracking purposes.

B. Objective and Outcome:

Objective. Enter the code of the objective that best describes the

purpose of the activity. If a code is not entered in IDIS, the system will

default the answer to “2” – Decent affordable housing.

1. Suitable living environments. Applies to activities that benefit

communities, families, or individuals by addressing issues in their

living environment.

2. Decent affordable housing. Applies to housing activities that

meet individual family or community needs. This objective should

not be used for activities where housing is an element of a larger

effort.

3. Creating economic opportunities. Applies to activities

related to economic development, commercial revitalization, and

job creation.

Outcome. Enter code of the outcome that best describes the benefits

resulting from the activity. If a code is not entered in IDIS, the system

will default the answer to “2” – Affordability.

1. Availability/accessibility. Applies to activities that make

services, infrastructure, housing, and shelter available and

accessible. Note that accessibility does not refer only to physical

barriers.

2. Affordability. Applies to activities that provide affordability in a

variety of ways. It can include the creation or maintenance of

affordable housing, basic infrastructure hookups, or services such

as transportation or day care.

3. Sustainability. Applies to activities that promote livable or

viable communities and neighborhoods by providing services or by

removing slums or blighted areas.

C. Household Characteristics.

Complete one line for each tenant receiving tenant-based rental

assistance from the HOME Program.

Tenant’s Last Name. Enter the tenant’s last name if the name is 5

letters or less. Enter the first five letters of the last name if the name is

more than five letters or a unique file identification number.

# of Bdrms. Enter 0 for a single room occupancy (SRO) unit or for an

efficiency unit, 1 for 1 bedroom, 2 for 2 bedrooms, 3 for 3 bedrooms, 4

for 4 bedrooms, and 5 for 5 or more bedrooms.

Sec Dep. Enter the amount of HOME funds to be paid to the tenant or

owner as a security deposit payment (to the nearest dollar).

Tenant Monthly Rent. Enter the actual rent, including utilities, to be

paid by the tenant at the time of activity completion (to the nearest

dollar). If the rent includes utilities, or, if the rent includes partial utilities,

e.g., heat, but not electricity, these utility costs must be added to the

rent. Compute utility costs for the area (and in the case of partial

utilities, compute costs for utilities excluded from the rent), by using the

utility allowance schedule produced by the local Public Housing

Authority (PHA).

TBRA Monthly Rent. Enter the amount of HOME funds to be paid to

the tenant or owner as a rent subsidy payment, including any utility

allowances (to the nearest dollar).

Total Monthly Rent. The total monthly rent is automatically calculated

by IDIS.

Household % of Med. For each household assisted with HOME funds,

enter one code only based on the following definitions:

1. 0 to 30% refers to a household whose annual income is at or

below 30 percent of the median family income for the area, as

determined by HUD with adjustments for smaller and larger

families.

2. 30+ to 50% refers to a household whose annual income exceeds

30 percent and does not exceed 50 percent of the median family

income for the area, as determined by HUD with adjustments for

smaller and larger families.

3. 50+ to 60% refers to a household whose annual income exceeds

50 percent and does not exceed 60 percent of the median family

income for the area, as determined by HUD with adjustments for

smaller and larger families.

4. 60+ to 80% refers to a household whose annual income exceeds

60 percent and does not exceed 80 percent of the median family

income for the area, as determined by HUD with adjustments for

smaller and larger families.

Household Hispanic? Y/N. For each household assisted with HOME

funds, enter the ethnicity of the head of household as either “Y” for

Hispanic or Latino or “N” for not Hispanic nor Latino. Hispanic or Latino

ethnicity is defined as a person of Cuban, Mexican, Puerto Rican,

South/Central American, or other Spanish culture or origin, regardless

of race. The term, “Spanish origin,” can be used in addition to “Hispanic

or Latino.”

Household Race. For each household assisted with HOME funds,

enter one code only based on the following definitions:

11. White. A person having origins in any of the original peoples of

Europe, North Africa or the Middle East.

12. Black/African American. A person having origins in any of the

black racial groups of Africa. Terms such as “Haitian” or “Negro”

can be used in addition to “Black or African American.”

13. Asian. A person having origins in any of the original peoples of

the Far East, Southeast Asia, or the Indian subcontinent including,

for example, Cambodia, China, India, Japan, Korea, Malaysia,

Pakistan, the Philippine Islands, Thailand and Vietnam.

14. American Indian or Alaska Native. A person having origins in

any of the original peoples of North and South America (including

Central America), and who maintains affiliation or community

attachment.

15. Native Hawaiian or Other Pacific Islander.

A person having

origins in any of the original people of Hawaii, Guam, Samoa or

other Pacific Islands.

16. American Indian/Alaska Native & White. A person having these

multiple race heritages as defined above.

17. Asian & White. A person having these multiple race heritages as

defined above.

18. Black/African American & White. A person having these

multiple race heritages as defined above.

19. American Indian or Alaska Native & Black or African

American. A person having these multiple race heritages as

defined above.

20. Other multi-racial. For reporting individual responses that are not

included in any of the other categories listed above.

Page 4 of 4 Revised (8/06)

Household Size. Enter the appropriate number of persons in the

household: 1, 2, 3, 4, 5, 6, 7, or 8 (for households of more than 8, enter

8).

Household Type. For each household assisted with HOME funds,

enter one code only based on the following definitions:

1. Single, non-elderly. One-person household in which the person is

not elderly.

2. Elderly. One or two person household with a person at least 62

years of age.

3. Single parent. A single parent household with a dependent child

or children (18 years old or younger).

4. Two parents. A two-parent household with a dependent child or

children (18 years old or younger).

5. Other. Any household not included in the above 4 definitions,

including two or more unrelated individuals.

Tenant Contract Paid To. Enter an O, if the TBRA Monthly Rent will

be paid to the Owner. Enter a T, if it will be paid to the Tenant.

Tenant Contract New? Enter a Y, if the tenant is newly assisted.

Enter an N, if the tenant’s assistance is being renewed.

Tenant Contract Months. Enter the number of months in the contract

with the tenant. Valid entries are 1 to 24.

D. Total/Subtotal of HOME Funds Requested.

Enter the total amount of HOME funds requested for the activity. This

amount includes the TBRA Monthly Rent for each tenant multiplied by

the Tenant Contract Months. It also includes the security deposit

amount for each tenant, if requested.

E. TBRA: Units

Number of TBRA units designated for the homeless. Of the total

number of TBRA units in the activity, enter the number designated for

the homeless. Homeless is defined as (1) an individual or family who

lacks fixed, regular, and adequate nighttime residence; or (2) An

individual or family who has a primary nighttime residence that is: (a) a

supervised publicly or privately operated shelter designed to provide

temporary living accommodations (including welfare hotels, congregate

shelters, and transitional housing for the mentally ill; (b) an institution

that provides a temporary residence for individuals intended to be

institutionalized; or (c) a public or private place not designed for, or

ordinarily used as, a regular sleeping accommodation for human

beings.

Of those, the number designated for the chronically homeless. Of

the number of units designated for the homeless, enter the number

designated for the chronically homeless. A chronically homeless

person is defined as an unaccompanied homeless individual with a

disabling condition who has either: (1) been continuously homeless for

a year or more, or (2) has had at least four episodes of homelessness in

the past three years. A disabling condition is defined as a diagnosable

substance use disorder, serious mental illness, developmental disability,

or chronic physical illness or disability. For the purpose of determining

chronically homelessness, a homeless person an unaccompanied

individual sleeping in a place not meant for human habitation or in an

emergency homeless shelter.

Note: IDIS will default to zero if units are not entered in these fields.

Faith-based Organization. Was this activity carried out by a faith-

based organization (y/N)? Enter “Y” if it is known or if the organization

declares itself to be a faith-based organization. If not, enter “N”.

Note: IDIS will enter the default answer of “N” if an answer is not typed

in the field.

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

Permanent Supportive Housing (PSH) Expansion TBRA Guidelines (Lake County)

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank Permanent Supportive Housing (PSH) Expansion TBRA Guidelines (Lake County) Form

Related forms

Fillable Permanent Supportive Housing (PSH) Expansion TBRA Guidelines (Lake County)

Fill Online, Printable, Fillable, Blank Permanent Supportive Housing (PSH) Expansion TBRA Guidelines (Lake County) Form

Related forms

First 20 documents completely FREE!