ILLINOIS ASSOCIATION OF REALTORS - DISCLOSURE OF INFORMATION AND ACKNOWLEDGMENT

DISCLOSURE OF INFORMATION AND ACKNOWLEDGMENT
LEAD-BASED PAINT AND/OR LEAD BASED PAINT HAZARDS

ILLINOIS ASSOCIATION OF REALTORS

DISCLOSURE OF INFORMATION AND ACKNOWLEDGMENT

LEAD-BASED PAINT AND/OR LEAD BASED PAINT HAZARDS

Lead Warning Statement

Every purchaser of any interest in residential real property on which a residential dwelling was built prior to 1978 is notified

that such property may present exposure to lead from lead-based paint that may place young children at risk of developing

lead poisoning. Lead poisoning in young children may produce permanent neurological damage, including learning disabilities,

reduced intelligence quotient, behavioral problems, and impaired memory. Lead poisoning also poses a particular risk to

pregnant women. The seller of any interest in residential real property is required to provide the buyer with any information on

lead-based paint hazards from risk assessments or inspections in the seller's possession and notify the buyer of any known

lead-based paint hazards. A risk assessment or inspection for possible lead-based paint hazards is recommended prior to

purchase.

PropertyAddress:__________________________________________________________________________________

Seller's Disclosure (initial)

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

Known lead-based paint and/or lead-based paint hazards are present in the housing (explain): ________________________________________________________________________________

________________________________________________________________________________

Seller has no knowledge of lead-based paint and/or lead-based paint hazards in the housing. _________(b) Records and Reports available to the seller (check one below):

Seller has provided the purchaser with all available records and reports pertaining to lead-based

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

________________________________________________________________________________

________________________________________________________________________________

Seller has no reports or records pertaining to lead-based paint and/or lead-based paint hazards

in the housing.

Purchaser's Acknowledgment (initial)

_________(c) Purchaser has received copies of all information listed above.

_________(d) Purchaser has received the pamphlet Protect Your Family From Lead in Your Home.

_________(e) Purchaser has (check one below):

Received a 10-day opportunity (or mutually agreed upon period) to conduct a risk assessment

or inspection of the presence of lead-based paint or lead-based paint hazards; or

Waived the opportunity to conduct a risk assessment or inspection for the presence of lead-

based paint and/or lead-based paint hazards.

Agent's Acknowledgment (initial)

_________(f ) Agent has informed the seller of the seller'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.

Seller ________________________ Date / / Purchaser ___________________ Date / /

Seller ________________________ Date / / Purchaser____________________ Date / /

Agent ________________________ Date / / Agent _______________________ Date / /

Form 420 Revised 8/2004 (This disclosure form should be attached to the Contract to Purchase)

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