Sample Disclosure Of Information On Lead-Based Paint Form printable pdf download

Sample Disclosure Of Information On Lead-Based Paint Form

Attachment B

DISCLOSURE OF INFORMATION ON LEAD-BASED PAINT

DISCLOSURE OF INFORMATION ON LEAD-BASED PAINT AND/OR LEAD-BASED PAINT HAZARDS

Lead Warning Statements

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____ Lessor has no knowledge of lead-based paint and/or lead based paint hazards in this apartment

community. Lessor has, therefore, no records and reports pertaining to lead-based paint and/or lead

based paint hazards.

B_____ Known lead-based paint and/or lead based hazards in this community (summarize):

Lessor has provided Lessee with a listing of the following records and/or reports pertaining to lead-based

paint and/or lead based paint hazards that are available upon residents request:

Lessee’s Acknowledgement (initial)

______Lessee has received a copy of the pamphlet “Protect Your Family From Lead in Your Home” and a

summary of all available records and reports itemized under section B above, if applicable.

Agent’s Acknowledgment (initial)

______ Agent has informed the lessor of the lessor’s obligations under 42 U.S.C. 4852d 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 provided by the signatory is true and accurate.

__________________________________________

_________

Lessee

Date

__________________________________________

_________

Lessee

Date

__________________________________________

__________

Agent/Lessor

Date

Sample Disclosure Of Information On Lead-Based Paint Form