Reset
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
(a) Presence of lead-based paint and/or lead-based paint hazards (check (i) or (ii) below):
(i) ______ Known lead-based paint and/or lead-based paint hazards are present in the housing
(explain).
(ii) _______Lessor has no knowledge of lead-based paint and /or lead-based paint hazards in the
housing.
(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 and/or lead-based paint
hazards in the housing.
Lessee’s Acknowledgement (initial)
(c) __________Lessee has received copies of all information listed above.
(d) __________Lessee has received the pamphlet Protect Your Family from Lead in Your Home.
Agent’s Acknowledgment (initial)
(e) __________Agent has informed the lessor of the lessor’s obligations under 42 U.S.C. 4852(d) 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 provided is true and accurate.
________________________________________
_______________________________________
Lessor
Date
Lessor
Date
__________________________________________________
________________________________________________
Lessee
Date
Lessee
Date
__________________________________________________
________________________________________________
Agent
Date
Agent
Date
NYCHA 059.018 (11/00)
1
