Lead-Based Paint Disclosure
Acknowledgement

Property Address:
LEAD WARNING STATEMENT
Every purchaser 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 that may place young children at risk of developing lead poisoning. Lead poisoning in young children may produce permanent neurological damage, including learning disabilities, reduced intelligence quotient, behavioral problems, and impaired memory. Lead poisoning also poses a particular risk to pregnant women. The seller of any interest in residential real estate is required to provide the buyer with any information on lead-based paint hazards from risk assessments or inspections in the seller's possession and notify the buyer of any known lead-based paint hazards. A risk assessment or inspection for possible lead-based paint hazards is recommended prior to purchase.

Seller's Disclosure

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

Purchaser's Acknowledgement

Purchaser has received copies of all information listed above.
Purchaser has received the pamphlet Protect Your Family from Lead in Your Home.
Purchaser has received a 10-day opportunity (or mutually agreed upon period) to conduct a risk assessment or inspection for the presence of lead-based paint and/or lead-based paint hazards.
Purchaser waives the opportunity to conduct a risk assessment or inspection for the presence of lead-based paint and/or lead-based paint hazards.

Signatures

Seller's Name:
Seller's Signature:
Date:
Purchaser's Name:
Purchaser's Signature:
Date:

Agent's Acknowledgement

Agent's Name:
Agent's Signature:
Date: