Roommate Substitution Agreement Template Page 4
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7Tenant Certification Form
Apt.Street Address
Unit#
(TENANT COPY)
Required Federal 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. The Massachusetts Tenant Lead Law Notification and Certification
Form is for compliance with state and federal lead notification requirements.
Owner’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)
Owner/Lessor has no knowledge of lead-based paint and/or lead-based paint
hazards in the housing.
(b) Records and reports available to the owner/lessor (Check (i) or (ii) below):
(i)
Owner/ Lessor has provided the tenant with all available records and reports
pertaining to lead -based paint and/or lead-based paint hazards in the housing
(circle documents below).
Lead Inspection Report;
Risk Assessment Report;
Letter of Interim Control;
Letter of Compliance
×
(iii)
Owner/Lessor has no reports or records pertaining to lead-based paint and/or
lead-based paint hazards in the housing.
Tenant’s Acknowledgment (initial)
(c)
Tenant has received copies of all documents circled above. (d)
Tenant has received no
documents listed above.
(e)
Tenant has received the Massachusetts Tenant Lead Law Notification.
Agent’s Acknowledgment (initial)
(f)
Agent has informed the owner/lessor of the owner’s/lessor’s obligations under federal and state
law for lead-based paint disclosure and notification 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.
Owner/Lessor
Date
Tenant
Date
Tenant
Date
Tenant
Date
Agent
Date
Agent
Date
Owner/Managing Agent Information for Tenant (Please Print):
The Hamilton Company
39 Brighton Avenue
Name
Street
Apt.
Allston MA
02134
(617) 783-0039
City/Town
Zip
Telephone
I (owner/managing agent) certify that I provided the Tenant Lead Law Notification/ Tenant
Certification Form and any existing Lead Law documents to the tenant, but the tenant refused to sign
this certification.
The tenant gave the following reason:
The Massachusetts Lead Law prohibits rental discrimination, including refusing to rent to families with
children or evicting families with children because of lead paint.
Contact the Childhood Lead Poisoning Prevention Program for information on the availability of this
form in other languages.
Tenant and owner must each keep a completed and signed copy of this form.
07/01/2009
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