Confirmation Of Receipt Form - 2006 printable pdf download

Confirmation of Receipt Form

Instructions: Complete all of Section 1, and either section 2,3, or 4, depending on the method of delivery

Section 1: Contractor/Owner Information

Contractor/Owner Name: __________________________________________________________

Address: _______________________________________________________________________

Phone: _________________________________________________________________________

Work site address: ________________________________________________________________

Date: __________________________________________________________________________

Section 2: Delivery in person and Tenant signature obtained

I have received a copy of the pamphlet, Protect Your Family From Lead in Your Home, informing me

of the potential risk of the lead exposure from renovation activity to be performed in my dwelling unit. I

received this pamphlet before the work began. I also received notification of renovation stating where

and when the renovation will be done.

__________________________________

____________________________________

Printed name of Tenant

Signature of Tenant

Section 3: Delivery in person; tenant signature not obtained

If lead pamphlet was delivered but a tenant signature was not obtainable, check the appropriate box below

□

Refusal to sign - I certify that I have made a good faith effort to deliver the pamphlet, Protect

Your Family From Lead in Your Home, and notification of renovation to the rental dwelling unit listed

above at the date and time indicated and that the occupant refused to sign the confirmation of receipt. I

further certify that I have left a copy of the pamphlet and notification of renovation at the unit with the

tenant.

□

Unavailable for signature – I certify that I have made a good faith effort to deliver the

pamphlet, Protect Your Family From Lead in Your Home, and notification of renovation to the rental

dwelling unit listed above and that the tenant was unavailable to sign the confirmation receipt. I further

certify that I have left a copy of the pamphlet and notification of renovation at the unit by sliding them

under the door.

__________________________________

____________________________________

Printed name of person certifying delivery

Signature of person certifying delivery

Section 4: Mailing Option

As an alternative to delivery in person, you may mail the lead pamphlet and notification of renovation to

the tenant. This information must be mailed at least 7 days before renovation (Document with a

certificate of mailing from the post office).

__________________________________

____________________________________

Printed name of person mailing

Signature of person mailing

Revised 6/19/06

Confirmation Of Receipt Form - 2006