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Qualified Offer Form - Maryland Department of the Environment

By Loretta Thomas,2014-05-06 11:40
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Qualified Offer Form - Maryland Department of the Environment

    MARYLAND DEPARTMENT OF THE ENVIRONMENT

    1800 Washington Boulevard, ? Suite 630 ? Baltimore, Maryland 21230-1719

    410-537-3825 ? 800-633-6101 x3825 ? http://www.mde.state.md.us

    Waste Management Administration ? Lead Poisoning Prevention Program

    QUALIFIED OFFER FORM Someone in Your Home Has a High Blood Lead Level What are Your Rights?

    Recently, you and your landlord received a notice from the local health department informing you that you

    or someone in your household has a level of lead in his/her blood that can be hazardous to that person's

    health. Lead is a poison that can cause learning disabilities, behavioral problems and permanent damage to

    vital organs.

    Because of that high blood lead level, your landlord, possibly through a representative like an insurer, has

    decided to make a Qualified Offer to help you through this problem. Now that you have received a Qualified

    Offer, your legal rights are very limited. If your landlord did everything the law requires him/her to do, you

    will not be able to sue your landlord for any damages that may have been caused by lead, even if you do not

    accept this Qualified Offer. So, if you think you are going to reject this Qualified Offer, be sure you

    completely understand this offer and how it affects your rights before you make a decision.

    The person making the Qualified Offer is offering: 1) to pay to move you and your family to a lead-safe

    home, and to help pay some of your rent; and 2) to pay certain bills related to the medical treatment of the

    person with the high blood lead level. The payments are limited to a maximum of $17,000 and in most cases

    will be made directly to the provider of services (physician, new landlord, etc.), not to you.

    Your landlord should also have given you two other pieces of information. One piece is about the dangers of

    lead poisoning and the other piece is about your rights under Maryland law. If you do not have this

    information, call the Lead Hotline at 410-537-4199 or 1-800-776-2706.

    It is very important that you read all of this material and understand your rights under this law before you

    decide to accept or reject this Qualified Offer.

    If you call the Lead Hotline at 410-537-4199 or 1-800-776-2706 you can get information about: the law, the

    Qualified Offer, your landlord's efforts to comply with the law, and the name of a counselor near your home

    who can help you get the information you need and help you complete the Qualified Offer form.

    There are two copies of the Qualified Offer attached to this flyer. If you wish to accept the offer, sign both

    copies and send one signed copy back within 30 days to the person who is making the offer. The address of

    that person is on the Qualified Offer. Be sure to keep one signed copy for yourself.

    Form Number: MDE/WAS/COM.056 Page 1 of 8 Date: 05/06/2010 TTY Users: 800-735-2258 Recycled Paper

    MARYLAND DEPARTMENT OF THE ENVIRONMENT

    1800 Washington Boulevard, ? Suite 630 ? Baltimore, Maryland 21230-1719

    410-537-3825 ? 800-633-6101 x3825 ? http://www.mde.state.md.us

    Waste Management Administration ? Lead Poisoning Prevention Program

    QUALIFIED OFFER

    Information About the Person with a High Level of Lead in His/Her Blood in Your Household:

    Date:

Dear: [Name of Person Who May Sign this Offer]

This Qualified Offer is made to help, [Name of the Person with a High Blood Lead Level] born on

     ([Date of Birth] if known), who was found to have a blood lead level of micrograms of lead per

    deciliter of blood on [Date of Test]. This Qualified Offer is made to you because you are either

    [Offeror checks one]:

     named above [Name of the Person with a High Blood Lead Level]; or

     A parent, legal guardian, or person appointed by the Court to make decisions for [Name of the Person

    with a High Blood Lead Level]. If you are not the person with a high blood lead level, the parent,

    legal guardian, or person appointed by the Court to make decisions for the person with a high blood

    lead level, please tell the person making this offer (listed on the next page) immediately.

Your Address is:

The Address of the Person with a high blood lead level is:

    Information About the Property Owner and the Person Making this Offer

The person making this Qualified Offer is:

Name:

    Company:

    Street Address:

City, State, Zip Code: ,

    Phone:

I am making this Qualified Offer to you because (Offeror checks one):

     I am your landlord.

     I represent your landlord's insurance company.

     I work for your landlord.

    Form Number: MDE/WAS/COM.056 Page 2 of 8 Date: 05/06/2010 TTY Users: 800-735-2258 Recycled Paper

    MARYLAND DEPARTMENT OF THE ENVIRONMENT

    1800 Washington Boulevard, ? Suite 630 ? Baltimore, Maryland 21230-1719

    410-537-3825 ? 800-633-6101 x3825 ? http://www.mde.state.md.us

    Waste Management Administration ? Lead Poisoning Prevention Program

The Owner of the Home in which the person with a high blood lead level resides (if it is not the person

    making this Qualified Offer)

Name:

    Street Address:

City, State, Zip Code: ,

    Phone:

    RELOCATION AND MEDICAL EXPENSES

    This is information about what the Qualified Offer provides you for relocation and medical expenses.

    Relocation Expenses If you sign this Qualified Offer, I will make payments to move your family to a lead-safe home and to help

    you pay the rent for the lead-safe home if the rent is higher than the rent you pay now. These expenses are

    called relocation expenses, and this section tells you more about the relocation expenses I will pay.

    These payments will end when I have spent $9,500 or when the child with lead in his/her blood turns 6 years

    old or, if the person with lead in her blood is a pregnant woman, when her baby turns 6 years old, whichever

    occurs first.

    THERE ARE TWO KINDS OF RELOCATION.

    Temporary Relocation is when I decide to repair the home you live in now in order to make it lead-safe. In

    that case, you will still have to move out of your home for a while because it would be very dangerous for

    somebody to live there while I am having the work done. Once the work is done and the property is lead-safe

    you will be allowed to move back in.

    If I decide that you should permanently relocate (discussed below) you may wish to move out of the house

    you live in now and live somewhere else for a short period while you locate a home for permanent relocation.

    We both must agree on this in order for you to do it.

    Permanent Relocation is when I decide that you should move to another home and that you will not return to

    the home you live in now. I may suggest different lead-safe places where the family may live. If you choose

    a lead-safe home which I suggest, I will make sure that it is lead-safe and provide you with documentation

    that it is lead-safe.

    You may also locate a home for permanent relocation without my help. If you do that, the home you choose

    must be lead-safe if you want me to make payments for relocation. A home that is lead-safe is one that was

    built after 1978, or certified lead-free, or has undergone certain treatments and inspections to demonstrate

    that it is lead-safe. Housing which has undergone these treatments and has windows with lead-free friction

    surfaces must also pass a final inspection for lead dust no more than 15 days before you move into the home.

    If you request it, I will pay for this inspection. If I make this payment, I will deduct the amount from the

    $9,500 that I will pay for relocation expenses.

    Form Number: MDE/WAS/COM.056 Page 3 of 8 Date: 05/06/2010 TTY Users: 800-735-2258 Recycled Paper

    MARYLAND DEPARTMENT OF THE ENVIRONMENT

    1800 Washington Boulevard, ? Suite 630 ? Baltimore, Maryland 21230-1719

    410-537-3825 ? 800-633-6101 x3825 ? http://www.mde.state.md.us

    Waste Management Administration ? Lead Poisoning Prevention Program

    Temporary Relocation I may decide that your family should move for only a short time while I make your current home lead-safe.

    You will not be able to move back into your home until it has been certified lead-safe.

    If I decide that you should relocate permanently (discussed on the next page) you may wish to relocate

    temporarily for a short period while you search for a place to move to permanently. We must both agree on

    this in order for you to do it.

    Unless you and I agree otherwise, temporary relocation will not last longer than 60 days. If your family is

    temporarily relocated, I will pay directly to the new landlord, or to other people who provide the family with

    services, the following temporary relocation costs.

    - Rent or per day cost of the temporary home;

    - The cost of moving, hauling or storing furniture or other personal belongings; and

    - Costs for special HEPA-vacuuming of all upholstered furniture.

    I will pay the family directly for additional expenses that are a result of the move to a temporary home, if

    you give me the receipts. These expenses can include:

    - Transportation;

    - Child care; and

    - Meal expenses if the temporary home does not have a place to cook.

    When you move back into your home after it has been made lead-safe, you will continue to pay the same rent

    as you paid before you received the Qualified Offer.

    Permanent Relocation If I think you should move immediately to a different home or if your family moves to a permanent home

    after being in a temporary home, I will pay directly to your landlord:

    - A rent subsidy as described below under the section Rent Subsidy; and

    - A security deposit, if any, for the lead-safe housing.

    I also will pay some of the costs of other things related to relocation. I will pay directly the people who

    provide the service for you and the things that I will pay for include:

    - Moving/hauling;

    Form Number: MDE/WAS/COM.056 Page 4 of 8 Date: 05/06/2010 TTY Users: 800-735-2258 Recycled Paper

    MARYLAND DEPARTMENT OF THE ENVIRONMENT

    1800 Washington Boulevard, ? Suite 630 ? Baltimore, Maryland 21230-1719

    410-537-3825 ? 800-633-6101 x3825 ? http://www.mde.state.md.us

    Waste Management Administration ? Lead Poisoning Prevention Program

- HEPA-vacuuming of all upholstered furniture; and

    - Installation and/or connection of utilities/appliances.

    I will pay you directly for other expenses if I am given a receipt. These expenses include:

    - Transportation;

    - Food for the first 24 hours; and

    - Child care.

    Rent Subsidy

    When your family is permanently relocated to a lead-safe home, if the rent of the home that you move to is

    higher than the rent you pay now, I will pay part of the rent according to a formula established by law.

    1. If the new rent is higher than your old rent, you will pay the same amount as the rent you pay now.

    2. I will pay an amount to cover the remainder of the rent up to an amount that is no more than 150% of

    the rent you pay now. The rent subsidy I pay is subtracted from the $9,500 total that I can pay for relocation

    expenses.

    3. If the total rent of the new home is actually greater than your rent PLUS the amount I pay, you will

    have to pay the additional amount.

    I may propose that you move to a home owned by your current landlord. If I do, I will tell you what the rent

    for that unit will be. That rent may be higher than rent you are paying now. If you agree to live there, the

    monthly rent payments will be made as follows:

    1. You will pay a rent that equals the rent you pay now.

    2. I will deduct an amount that is no more than 150% of your current rent from the $9,500 I can pay for

    relocation expenses.

    3. If the total rent of the home you move to is actually greater than your rent PLUS the maximum

    amount I can deduct as a rent subsidy, you will have to pay the additional amount.

Form Number: MDE/WAS/COM.056 Page 5 of 8 Date: 05/06/2010 TTY Users: 800-735-2258 Recycled Paper

    MARYLAND DEPARTMENT OF THE ENVIRONMENT

    1800 Washington Boulevard, ? Suite 630 ? Baltimore, Maryland 21230-1719

    410-537-3825 ? 800-633-6101 x3825 ? http://www.mde.state.md.us

    Waste Management Administration ? Lead Poisoning Prevention Program

Maximum Rent Subsidy Amount

    The rent you pay now is $ month. (select one) The rent subsidy I will pay or deduct can be no more than: $ month (select one) 150% of the rent you pay now.

    MEDICALLY NECESSARY TREATMENTS

    If you sign this Qualified Offer, I also will pay up to a total of $7,500 for reasonable, medically necessary

    treatments needed because of the high blood lead level, but only when these costs are not paid for by your

    insurance, Medicaid or any other third-party provider. If the person with a high blood lead level is a child, I

    will pay these expenses until that child is 18 years old or until the $7,500 runs out, whichever happens first. I

    will make the payments for reasonable, medically necessary treatments directly to the health care provider,

    not to you. Medically necessary treatments include:

    - Educational evaluation

    - Psychometric testing

    - Inpatient treatment

    - Outpatient treatment

    - Behavioral therapy

    - Speech and language therapy

    - Medicine needed to treat lead poisoning or medical problems caused by high blood lead levels

    - Nutritional evaluation

    - Standard, over-the-counter vitamins with minerals, and iron and calcium supplements prescribed or

    recommended by your doctor

    - Any other treatment related to high blood lead level deemed necessary by a health care provider

    Form Number: MDE/WAS/COM.056 Page 6 of 8 Date: 05/06/2010 TTY Users: 800-735-2258 Recycled Paper

    MARYLAND DEPARTMENT OF THE ENVIRONMENT

    1800 Washington Boulevard, ? Suite 630 ? Baltimore, Maryland 21230-1719

    410-537-3825 ? 800-633-6101 x3825 ? http://www.mde.state.md.us

    Waste Management Administration ? Lead Poisoning Prevention Program

    Certification by Landlord

    THIS IS THE SECTION YOUR LANDLORD, OR SOMEONE REPRESENTING YOUR

    LANDLORD, COMPLETES TO SHOW YOU THAT EVERYTHING THE LAW REQUIRES HAS

    BEEN DONE.

    As the owner of , [address of affected property], under the penalties of perjury, I certify that I have

    complied with all applicable provisions and requirements under Environment Article, Title 6, Subtitle 8,

    Annotated Code of Maryland. Specifically, I have complied with the following requirements:

    1. REGISTRATION

    I have registered this affected property with the Maryland Department of the Environment.

    2. RISK DEDUCTION [check all that apply]

     I met the full Risk Reduction standard on [date].

     I responded to all notices of defects in the affected property by meeting the Modified Risk Reduction

    Standard on [date].

     I responded to a notice that a person at risk in this unit was diagnosed with a high blood lead level of

    15 micrograms/deciliter or more before February 24, 2006, or 10 micrograms/deciliter on or after February

    24, 2006, by meeting the Modified Risk Reduction Standard on [date], which was within 30 days of

    receiving the notice of high blood lead level.

     I had no obligation to meet a Risk Reduction Standard.

    3. TENANT'S RIGHTS NOTICE

    I gave the Notice of Tenant's Rights to the household of the person at risk in a timely manner on

    [date].

    4. LEAD INFORMATION PACKET

    I gave the Lead Information Packet to the household of the person at risk in a timely manner on [date].

    ______________________________________ ___________________________________

    Signature of Owner Date

______________________________________ ___________________________________

    Signature of Witness Date

    Form Number: MDE/WAS/COM.056 Page 7 of 8 Date: 05/06/2010 TTY Users: 800-735-2258 Recycled Paper

    MARYLAND DEPARTMENT OF THE ENVIRONMENT

    1800 Washington Boulevard, ? Suite 630 ? Baltimore, Maryland 21230-1719

    410-537-3825 ? 800-633-6101 x3825 ? http://www.mde.state.md.us

    Waste Management Administration ? Lead Poisoning Prevention Program

    Maryland Department of the Environment Tracking Number: Maryland Department of the Environment Property Number of the property in which the person with high

    blood lead level resides (if available):

    ACCEPTANCE OF THE QUALIFIED OFFER THIS IS THE SECTION YOU COMPLETE IF YOU ACCEPT THE QUALIFIED OFFER

    If you wish to accept this Qualified Offer, you must sign both copies of this form and return one copy to me

    within 30 days of receipt.

    If you do not accept this Qualified Offer within 30 days, you may not be able to sue your landlord for any

    injuries or illness that may have been caused by a high blood lead level and will not receive the benefits

    outlined in the Qualified Offer.

    I, (print your name) hereby accept this Qualified Offer on my own behalf or on behalf of (print

    the name of person in your home with high blood lead level).

______________________________________ ___________________________________

    Signature Date

______________________________________ ___________________________________

    Signature of Witness Date

Form Number: MDE/WAS/COM.056 Page 8 of 8 Date: 05/06/2010 TTY Users: 800-735-2258 Recycled Paper

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