Lead-Based Paint Disclosure Form
Property Information
Property Address
City, State, ZIP
Lessor's Disclosure
Known lead-based paint and/or lead-based paint hazards are present in the housing.
Lessor has no knowledge of lead-based paint and/or lead-based paint hazards in the housing.
Additional explanation (if applicable)
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.
Lessor has no reports or records pertaining to lead-based paint and/or lead-based paint hazards in the housing.
List any documents provided (if applicable)
Lessee's Acknowledgment
Lessee has received the pamphlet Protect Your Family from Lead in Your Home.
Lessee has received the records, reports, and information identified above.
Agent's Acknowledgment
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.
Signatures
Lessor's Signature
Date
Lessee's Signature
Date
Agent's Signature
Date