Caring Breaths Radon Mitigation Expenses Application Form 1. Contact Information First Name Last Name Phone Number Email Mailing Address City Postal Code State/Province - None - Is the residence you are requesting reimbursement for your primary residence? Yes No 2. Radon Mitigation Expense Receipts Attach a copy of the receipt you are requesting financial reimbursement for. Note: Radon mitigation must be completed by a Canadian-National Radon Proficiency Program (C-NRPP) radon reduction expert to lower radon levels below Health Canada’s recommended guideline of 200 Bq/m3 for the applicant's primary residents. Maximum 5 files.2 GB limit.Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. 3. Income Verification What is your net disposable income? (monthly income after taxes) Choose range that applies to you. $500 or less $500 - $1000 $1000+ 4. Other Financial Support Select any other organizations you have received financial support from to help cover related costs. Lungs Matter - www.lung.ca Other… Enter other… 6. Did you or your certified radon mitigator test your home pre-mitigation? yes no 6 a. Where did you get your radon test from? 6 b. What kind of radon test was used? testwhatoptions Long Term Alpha Track detector E-Perm Continuous Radon Monitor Other (please specify) Enter other… 6 c. What was the radon level in your home pre-mitigation? radonleveloptions Under 200 Bq/m3 200 Bq/m3-400 Bq/m3 600 Bq/m3 + 7. Does anyone living in the home have or had lung cancer? lungcanceroptions Yes No Optional: Other Information You may use this field to provide any other information you feel is relevant or important to your application. To find out more visit Caringbreaths.ca or If you have any questions about our Caring Breaths program, please email caringbreaths@lungsask.ca Leave this field blank
