Lead-Based Paint Disclosure
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L
-B
P
D
EAD
ASED
AINT
ISCLOSURE
Federal law mandates that Sellers of housing constructed prior to 1978 must complete certain Lead-Based Paint Disclosure
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requirements. These should be completed before the Buyer makes an offer and certainly before the Seller accepts a purchase
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offer, otherwise the Buyer may not be obligated under any contract to purchase such housing.
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PROPERTY ADDRESS: _________________________________________________________________________________
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BUYER NAME(s) (printed): ______________________________________________________________________________
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SELLER NAME(s) (printed): _____________________________________________________________________________
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LEAD WARNING STATEMENT
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Every purchaser of any interest in residential real property on which a residential dwelling was built prior to 1978 is notified
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that such property may present exposure to lead from lead-based paint that may place young children at risk of developing lead
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poisoning. Lead poisoning in young children may produce permanent neurological damage, including learning disabilities,
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reduced intelligence quotient, behavioral problems, and impaired memory. Lead poisoning also poses a particular risk to
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pregnant women. The seller of any interest in residential real property is required to provide the buyer with any information on
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lead-based paint hazards from risk assessments or inspections in the seller’s possession and notify the buyer of any known lead-
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based paint hazards. A risk assessment or inspection for possible lead-based paint hazards is recommended prior to purchase.
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SELLER DISCLOSURE
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Seller to check one box below:
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Seller has no knowledge, records, or reports of lead-based paint and/or lead-based paint hazards in the housing.
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Seller is aware of the presence of lead-based paint and/or lead-based paint hazards and has provided the Buyer with
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all available records and reports pertaining to lead-based paint and/or lead-based paint hazards in the housing.
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List any records, reports and/or additional information: _____________________________________________________
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_________________________________________________________________________________________________
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BUYER ACKNOWLEDGMENT
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(a) Buyer has received copies of all records, reports and information listed above (if any), and
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(b) Buyer has read the Lead Warning Statement (above) and understands its contents, and
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(c) Buyer has received the lead hazard information pamphlet Protect Your Family from Lead in Your Home
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(copies available at ), and
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(d) Buyer has received a 10-day opportunity (unless the parties mutually agreed upon a different period of time)
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before becoming obligated under the contract to purchase the housing to conduct a risk assessment or inspection
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for the presence of lead-based paint hazards. This opportunity is waived if buyer checks the second box below.
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Buyer to check one box below:
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Contract is subject to Buyer's approval of the results of a risk assessment or inspection of the property for the
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presence of lead based paint and/or lead based paint hazards, to be completed at the Buyer's expense. This
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contingency shall be satisfied within 10 calendar days from the Binding Agreement Date.
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Buyer waives the opportunity to conduct a risk assessment or inspection for the presence of lead-based paint
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and/or lead-based paint hazards.
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LICENSEE ACKNOWLEDGMENT
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Licensees have informed the Seller of the Seller’s obligations under 42 U.S.C. 4852d (see ), and are aware
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of listing and selling licensees' duty to ensure compliance.
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CERTIFICATION OF ACCURACY
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The Sellers, Buyers, and Licensees have reviewed the information above and certify, to the best of their knowledge, that the
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information they have provided is true and accurate.
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X_______________________________________________ X____________________________________________________
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Buyer Signature
Date & Time
Buyer Signature
Date & Time
X_______________________________________________ X____________________________________________________
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Seller Signature
Date & Time
Seller Signature
Date & Time
X_______________________________________________ X____________________________________________________
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Licensee Signature
Date & Time
Licensee Signature
Date & Time
Page 1 of 1
01/01/2013
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