Residential Real Property Disclosure Statement Form Page 2
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2Acknowledgement of federal 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 Acknowledgement (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
Lessor
Date
____________________________________
_________________________________________
Lessee
Date
Lessee
Date
____________________________________
_________________________________________
Agent
Date
Agent
Date
Maine Health & Human Services, Public Health
2
9/22/2005
Property Lease Form
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