lead disclosure

lead disclosure.doc (81.1 KiB)




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):

___  (i) Known lead-based paint and/or lead-based paint hazards are present (explain): _______________________________________________________________.

___  (ii) Lessor has no knowledge of lead-based paint and/or lead-based paint hazards.

(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
(e)_______ Lessee has had a 10 day period to inspect the premises for lead or has waived the same

Agent’s Acknowledgment (initial)

(f)_______ 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

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