Disclosure of Information on Lead-Based Paint and Lead-Based Paint Hazards

Lead Warning Statement

Housing built before 1978 may contain lead-based paint. Lead from paint, paint chips and dust can post health hazards if not taken care of properly. Lead exposure is especially harmful to young children and pregnant women. Before renting pre-1978 housing, landlords must disclose the presence of known lead-based point and lead-based paint hazards in the dwelling. Tenants must also receive a Federally approved pamphlet in lead poisoning prevention.

Lessor's Disclosure (initial)

[Lessor's Initials] (a) Presence of lead-based point or lead-based paint hazards (check one below)

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

[ ] Lessor has no knowledge of lead-based paint and/or lead based paint hazards in the housing.

[Lessor's Initials] (b) Records and reports available to the lessor (check one below)

[ ] Lessor has provided the lessee with all available records and reports pertaining to lead-based paint and/or lead-based paint hazards in the housing. (List documents below)

[ ] Lessor has no reports or records pertaining to lead-based paint and/or lead-based paint hazards in the housing.

Lessee's Acknowledgement (initial)

[Lessee's Initials] (c) Lessee has received copies of all information listed above.

[Lessee's Initials](d) Lessee has received the pamphlet Protect Your Family from Lead in Your Home

Agent's Acknowledgement (initial)

______ (e) Agent has informed the lessor of the lessor's obligations under 42 U.S.C. 4852(d) 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 provided by the signatory is true and accurate.

Lessor Name: [Lessor Name]
Date: [Date Signed]

Lessee Name: [Lessee Name]
Date: [Date Signed]