Disclosure of Information on Lead-Based Paint and/or Lead-Based Paint Hazards
Lead Warning Statement
Housing built before 1978 may contain lead-based paint. Lead from paint, paint chips, and dust can pose health hazards if not managed properly. Lead exposure is especially harmful to young children and pregnant women. Before renting pre-1978 housing, lessors must disclose the presence of known lead-based paint and/or lead-based paint hazards in the dwelling. Lessees must also receive a federally approved pamphlet on lead poisoning prevention.
Lessor's Disclosure
(a) Presence of lead-based paint and/or lead-based paint hazards (check (i) or (ii) below):
(i)_____Known lead-based paint and/or lead-based paint hazards are present in the housing
(explain).
(ii)_____ Lessor has no knowledge of lead-based paint and/or lead-based paint hazards in the
housing.
(b) Records and reports available to the lessor (check (i) or (ii) below):
(i)_____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).
(ii)_____ Lessor has no reports or records pertaining to lead-based paint and/or lead-based
paint hazards in the housing.
Lessee's Acknowledgment (initial)
(c) _______Lessee has received copies of all information listed above.
(d) _______Lessee has received the pamphlet Protect Your Family from Lead in Your Home.
Agent’s Acknowledgment (initial)
(e)   ________Agent has informed the lessor of the lessor'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.
Lessor                                                 Date                 Lessor                                                        Date
Lessee                                               Date                 Lessee                                                      Date
Agent                                                 Date                 Agent                                                       Date

 

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