Lead-Based Paint Disclosure

Property Address:

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

Known lead-based paint and/or lead-based paint hazards are present in the housing (explain):
Lessor has no knowledge of lead-based paint and/or lead-based paint hazards in the housing.
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):
Lessor has no reports or records pertaining to lead-based paint and/or lead-based paint hazards in the housing.

Lessee's Acknowledgment

Lessee has received the pamphlet "Protect Your Family from Lead in Your Home."
Lessee has received all information and reports listed above.

Agent's Acknowledgment (if applicable)

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 Signature
Date
Lessee Signature
Date
Agent Signature
Date