HomeMy WebLinkAbout2026_LSLR_Program_Application_Form
I:\Engineering\Lead Service Lateral Replacement\2026 Program\New documents\2026 LSLR Program Application
Form_1-5-26.docx
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City Hall, 215 Church Avenue P.O. Box 1130 Oshkosh, WI 54903-1130 http://www.oshkoshwi.gov
Return to Tracy Taylor:
Via e-mail: dpw@oshkoshwi.gov
Via mail: Department of Public Works
PO Box 1130
Oshkosh, WI 54903-1130
In person: Room 301, City Hall
215 Church Avenue
2026 FINANCIAL ASSISTANCE APPLICATION FOR
PRIVATE-SIDE LEAD SERVICE LINE REPLACEMENT
Application, including Waiver/Release and Consent to Special Charge forms, must be submitted to be considered.
APPROVAL OF THE PROPERTY IS REQUIRED BEFORE COMMENCING WORK
Approval for the Lead Water Service Replacement financial assistance is required before commencing work.
Properties must be deemed eligible before the start of replacement work to ensure that Federal requirements for the
Endangered Species, Archeological/Historical, and Waterway/Wetland Reviews have been completed. Some
properties may not be eligible for reimbursement due to these reviews or may require additional time to complete
the process due to location and property history. The City of Oshkosh (City) will provide a written response to the
approval application. Please note any conditions included in the response and share them with your contractor.
The response will include the maximum amount of financial assistance the property is eligible to receive.
Approvals are valid for nine (9) months.
Verification of the property’s water service line materials is required before approval. Visit the
City’s online Water Service Inventory to view your property by using the QR code to the right. The
Private-Side Service Line pipe material must be lead, galvanized iron (considered lead), or brass for
the replacement to be eligible for financial assistance. If the material type is listed as “unknown”,
please schedule an appointment for a free inspection using the link from the Inventory or call (920)
232-5336. If you do not have access to use this QR code, you may call (920) 232-5336 to find out if the City has
already identified your material type or visit www.oshkoshwater.com.
Lead Service line replacement should be coordinated so the public-side and private-side are completed within
90 days of each other and must be done within 180 days of either side becoming lead-free. Failure to meet the
180-day requirement may result in the property not being eligible for financial assistance. The 180-day
requirement does not apply to partial replacements completed before August 8, 2024.
HOUSEHOLD INFORMATION
Property Owner’s Name(s): ___________________________________________________________________________
(If business or corporation, provide the name and title of the individual who can sign legal documents.)
Property Address: ____________________________________________________________________________
____________________________________________________________________________
Mailing Address: ____________________________________________________________________________
(if different than above)
____________________________________________________________________________
Home Phone: ___________________________ Cell Phone: _______________________________________
E-mail Address: _____________________________________________________________________________________
The City will use this e-mail address to communicate important information about the program. Please check this
Box if you do not wish to receive information via e-mail:
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Is the property used for a licensed childcare facility or school? (Check one) Yes ____ No ____
List the dates of birth for all children living or routinely spending significant time at this address or property:
_____________________________________________________________________________________________________
Are any members of the household currently pregnant? (Check one) Yes ____ No ____
Are any residents of the property currently immunocompromised? (Check one) Yes ____ No ____
Has the Private-Side Lead Service Line Replacement been completed?
NO YES, Date Completed ____________________________________ ______________________
Is the Private-Side Lead Service Line Replacement due to a leak?
YES NO, Reason for Replacement ________________________ ______________________
I attest that the above information is correct and consent to the review of my property for the purpose of
determining eligibility requirements of the Lead Service Line Replacement Program.
Property Owner’s Signature: __________________________________________________________________________
Date: _______________________________________________________________________
A signed Lead Service Line Replacement Financial Assistance Program Waiver/Release of Liability and signed
Lead Service Line Replacement Financial Assistance Program Consent to Special Charge (attached) must be
returned with this document. Please call (920) 236-5258 if you need assistance determining the Parcel Number
of your property.
DAVIS-BACON WAGE RATE REQUIREMENTS
Funding for private-side lead water service line replacement is being provided by the Bipartisan Infrastructure Law.
Therefore, the Federal Davis-Bacon wage rate requirements will apply in the following circumstances:
The property is owned by an individual or individuals or is in the name of a business.
The work will be performed using a plumbing/utility contracting firm that has employees (who are not 20%
owners of this firm), and an owner of that plumbing/utility contracting firm did not perform one hundred
percent (100%) of the work.
Davis-Bacon wage rate requirements will not apply in the following circumstances:
An employee who is at least a twenty percent (20%) owner of the plumbing/utility contracting firm completing
the work completes one hundred percent (100%) of the work.
The total cost of the LSL replacement is less than $2,000.
The City will assist in determining whether or not the Davis-Bacon wage rate requirements apply.
The plumber/utility contractor must provide a certified payroll to the City on the U.S. Department of Labor’s
Payroll form with the reimbursement application form.
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Waiver Release of Liability_1-5-26.docx
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2026 LEAD SERVICE LINE REPLACEMENT FINANCIAL ASSISTANCE PROGRAM
WAIVER/RELEASE OF LIABILITY
NOTE: THIS IS A LEGAL DOCUMENT
1. The City of Oshkosh (City) has created a program to help City residents pay for some of the costs needed
to replace their water service pipes that contain lead. The program is made possible through funding
received from the Wisconsin Department of Natural Resources.
2. I own property within the Oshkosh City limits. The description of my property is as follows:
Address: _______________
Parcel No: _______________
3. I understand that participating in this Lead Water Service Line Replacement Financial Assistance Program
is voluntary. The pipe that I hope to receive financial assistance for is my private pipe on my own property
and within the adjacent public right-of-way to the curb stop. I will need to hire a contractor to replace my
lead water service pipe. I am responsible for whatever work is done.
4. The City has created a list of pre-qualified contractors. These contractors have stated they are willing to
replace lead water service pipes and will abide by the program requirements. I understand the City has
created this list as a convenience for homeowners like me. The City has verified the contractors on this list
have met the qualifications of being licensed utility contractors and/or plumbers, and these contractors
have agreed to follow all program requirements.
The City does not warranty, guaranty, or state that individual contractors on the list will be qualified to do
the work on my property, or that I will get along with the contractor, or that I will agree with their
contract, or how they go about completing the work. I understand that things can go wrong on any
construction job. Therefore, it is my responsibility to investigate the contractors on the City’s list and find
the one that I think will be the best for me, in terms of price, contract terms, and the actual work they will
do. I understand that I will be the one responsible for hiring a contractor. My agreement is with the
Contractor, and is not an agreement with the City. The City does not have an agreement for this Program
with the Contractor.
5. The City’s main involvement in this project on my property is to financially assist me for some of the work
that I hire a contractor to do on my property as long as I meet the program qualifications.
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6. Release of Liability. I hereby release the City of Oshkosh, its officers, employees, agents, representatives,
and insurers, including all of the assignees and successors in interest from all claims based upon the
actions and/or inactions of the City of Oshkosh, its officers, employees, agents, and/or representatives,
related to or occurring in connection with my participation in the Lead Service Line Replacement Financial
Assistance Program. The claims released in this paragraph include those which may be based upon State
or Federal statutes and/or administrative codes, common law, and Municipal and/or County Ordinances.
The potential injuries and claims resulting from the identified type of events include, but are not limited to,
monetary losses, as well as physical and psychological injuries of all levels of seriousness.
I understand that by signing this Release that I am not releasing the one (1) or more contractors that I hire
to perform the lead water service pipe replacement; nor Third persons, including plumbers/utility
contractors, based upon their negligent, reckless, willful, and malicious actions; and that those Third
parties and their actions are not part of this agreement and are not released. Third persons are meant to
include all persons other than the City of Oshkosh, its officers, employees, agents, and/or representatives.
I understand that in order for the City to make sure this program works for everyone, it has to be clear that
I am entering into agreements with contractors based on my own choice, and not based on any choice or
direction the City has made for me.
I understand that if I didn’t agree to the terms of this Waiver/Release, the City may be unable to offer
financial assistance through the Lead Service Line Replacement Financial Assistance Program or that the
opportunities for me to participate in this program may be limited.
I hereby waive the right to make a claim as noted above and waive my rights to negotiate or bargain for
different terms of this waiver and release of claims, which may lead to more potential liability on the part
of the City of Oshkosh, its officers, employees, agents, and/or representatives, and may limit my
participation or increase my costs under this program.
I understand that, in order for me to participate in the Lead Service Line Replacement Financial Assistance
Program, an agreement for waiver/release in some form is required. For reasons that have value to me, I
have chosen to accept the terms as identified within this document.
Property Owner:
_______________________________________________ _____________________________________
Signature Printed Name
_______________________________________________ _____________________________________
If applicable, name of business or corporation and title of person signing. Individual must have the authority
to sign legal documents for the above business/corporation.
_____________________________
Date
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Owner Consent to Special Charge_1-5-26.docx
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2026 LEAD SERVICE LINE REPLACEMENT FINANCIAL ASSISTANCE PROGRAM
CONSENT TO SPECIAL CHARGE
NOTE: THIS IS A LEGAL DOCUMENT
I am applying for financial assistance available through the City of Oshkosh Lead Service Line
Replacement Financial Assistance Program for the replacement of a lead water service line (LSL) or
galvanized iron water service line, considered LSL, servicing the Property, which I own and which is
described below:
Property Address:
Parcel No:
I understand that, under the City’s Lead Service Line Replacement Financial Assistance Program
(Program), I will choose a contractor(s) who will replace the lead service line on my Property, but that
the City will pay that contractor(s) after work is completed, up to a maximum of $5,400 for plumbing
costs and $1,300 in hard surface restoration costs. I understand that I am responsible for any amounts
charged for work performed above these maximum amounts.
I understand that, as a part of the Program, I will be required to sign an agreement at the completion of
the work to allow the City to disburse the funds. I understand that it is very important that I cooperate
with the City and respond promptly to requests for information and to requests for completion of the
required paperwork under the Program to allow the City to promptly reimburse the contractor(s) who
performed work and to comply with the City’s Lead Service Line Assistance Program and State of
Wisconsin Loan Program requirements.
I understand and agree that if my application is approved, repayment of the Lead Service Line
Assistance Loan amount will be secured by the City’s right to special charge as provided by §66.0627
of the Wisconsin Statutes.
To that end, if my application is approved, I agree that I will promptly respond to requests for
information and promptly, within 7 calendar days of the date that City staff contacts me to schedule a
meeting to sign the required agreement or sign or provide any other paperwork that the City may
require from me, schedule a meeting and attend that meeting to complete the necessary paperwork to
allow the City to disburse payment to the contractor(s) that I have chosen and to complete the process
for purposes of the Lead Line Financial Assistance Program.
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I further agree that if my application is approved, the work is performed and I fail to promptly
respond or comply with the Program requirements, that the City may proceed with payment to the
contractor of the amount eligible for payment under the City’s Lead Line Financial Assistance
Program and levy the amount of the financial assistance provided to me, up to the maximum of
$5,400 for plumbing costs and $1,300 in hard surface restoration costs against the Property as a
special charge pursuant to Wis. Stat. §66.0627(8)(ag). In connection therewith, I:
(i) acknowledge that the City will have incurred financial obligations in connection with my
application and acceptance into the Program and in connection with payment of the contractor(s)
who will have performed work and that the work performed will have benefited my Property;
(ii) agree that the amount of the special charge, if levied, constitutes a proper exercise of the
City’s authority to levy special charges in accordance with Wis. Stat. §66.0627(8)(ag)-(cm);
(iii) agree that the allocation of the amount of the special charge to the Property, up to the
maximum of $5,400 for plumbing costs and $1,300 in hard surface restoration costs, is reasonable;
(iv) consent to the imposition and levy of such special charge;
(v) agree that the levy of special charges is authorized by signature on this Consent Agreement,
and that no further procedural steps need be taken by the City;
(vi) waive all notices, hearings, and appeals provided by Wis. Stat. §66.0627 or any other statute;
(vii) acknowledge that the City is relying on the terms of this Agreement, and specifically the
terms of this Subsection in reviewing and accepting my application, and that if special charges
were not enforced that this would be inequitable to both the contractor(s) that performed the
work and the City who will pay for the work based upon my representations herein; and
(viii) understand and agree that the City will follow its customary practice in collecting special
charges placed on the tax rolls, including assessing penalties and charging interest, and initiating
foreclosure proceedings where appropriate.
Special charges collected for private LSL replacement loan repayments shall be placed in a segregated
fund and disbursed in accordance with the requirements of the City’s funding sources.
City shall keep an accounting of private LSL charges made in connection with this agreement and
payments received by the City and provide Property Owner with such information upon request.
Property Owner:
_____________________________________ ____________________________________
Signature Printed Name
_________________________________ _____________________________________
If applicable, name of business or corporation and title of person signing. Individual must have the
authority to sign legal documents for the above business/corporation.
_____________________________
Date