Disclosure of Information on Lead-Based Paint or 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 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 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 USC 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