California Lead-Based Paint Disclosure Form

Lead Warning Statement

Every purchaser/tenant of any interest in residential real property on which a residential dwelling was built prior to 1978 is notified that such property may present exposure to lead from lead-based paint. Lead poisoning in young children may produce permanent neurological damage. Sellers/lessors and real estate agents are required to provide purchasers/tenants with information on lead-based paint hazards.

Seller’s/Owner’s Disclosure

Known lead-based paint and/or lead-based paint hazards are present in the housing.
Seller/Owner has no knowledge of lead-based paint and/or lead-based paint hazards in the housing.
Seller/Owner has provided the purchaser/tenant with all available records and reports pertaining to lead-based paint and/or lead-based paint hazards in the housing.
Seller/Owner has no reports or records pertaining to lead-based paint and/or lead-based paint hazards in the housing.

Purchaser’s/Tenant's Acknowledgment

Purchaser/Tenant has received copies of all information listed above.
Purchaser/Tenant has received the pamphlet Protect Your Family From Lead in Your Home.

Agent's Acknowledgment

Agent has informed the seller/owner of the seller’s/owner’s obligations under 42 U.S.C. 4852d and is aware of his/her responsibility to ensure compliance.

Signatures

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