Lead in Schools—Reimbursement Program

Welcome

Please read the reimbursement guidance document on the DEQ website prior to completing this form.

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* 1. Is this a school or childcare facility?

School

Childcare Facility

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* 2. School or Childcare Facility Name

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* 3. School or Childcare Facility ID Number (ie MTOPIXXXX)

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* 4. Contact Person

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* 5. Contact Person Phone #

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* 6. Contact Person Email

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* 7. Mailing Address

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* 8. Description of Lead Mitigation Performed

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* 9. Reimbursement Amount Requested $$ (maximum of $100,000/school)

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* 10. Upload Invoices, Receipts, and/or Supporting Documents (16 mb max) (Non-anonymous question)

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* 11. I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information; including the possibility of fine and imprisonment for knowing violations. [75-5-633, MCA]

Select this box in order to certify