Sublet Application Form Page 14
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19Disclosure of information on Lead-based Paint and/or Lead-Based Paint Hazards
RENTALS
Property Address:
_
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 are present 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 records or reports pertaining to lead-based paint and/or lead-based paint hazards in the
housing.
Lessee’s Acknowledgment (initial)
(c)
Lessee has received copies of all information listed above.
Lessee has received the pamphlet Protect Your Family from Lead in Your Home.
(d)
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 have provided is true and accurate.
_
_
LESSOR
DATE
CO-LESSOR
DATE
_
_
LESSEE
DATE
CO-LESSEE
DATE
_
_
AGENT
DATE
AGENT
DATE
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