Lead Based Paint Disclosure Form

Sample Lead Based Paint Disclosure Form

Disclosure of Information on Lead-Based Paint and/or Related Hazards

Lead Warning

Structures built before 1978 may contain lead-based paint. Lead from this paint, paint chips, and dust can pose health hazards if not properly managed.  Lead exposure is especially harmful to pregnant women and young children.  Lessors of dwellings built before 1978 are required by law to disclose the presence of known lead-based paint and/or lead-based paint hazards in the property to be rented.  Lessees must also be provided with a copy of a federally-produced pamphlet on lead poisoning prevention.

Landlord’s disclosure

Presence of lead-based paint and/or lead-based paint hazards (check below):

______ Known lead-based paint and/or lead-based paint hazards are present in the dwelling (explain): ______________________________________________

_______________________________________________________________

______ Landlord has no knowledge of lead-based paint and/or lead-based paint hazards in the dwelling.

Records and reports available to the tenant (check below):

______ Landlord has provided the tenant with all available records and reports pertaining to lead-based paint and/or lead-based paint hazards in the housing, including these documents: _________________________________________

______ Landlord has no reports or records pertaining to lead-based paint and/or lead-based paint hazards in the housing.

Tenant’s Acknowledgement

______  Tenant has received copies of all information listed above.

______  Tenant has received the pamphlet Protect Your Family from Lead in Your Home.

Agent’s Acknowledgement
 

______  Agent has informed the landlord of the landlord’s obligations under 42 U.S.C. 4852d and is aware of his/her responsibility to ensure compliance.

Certificate of Accuracy
The following parties have reviewed the above information and certify that the information they have provided is true and accurate.


__________________________________                       __________________________________
Landlord                                                      Date                       Landlord                                                     Date

__________________________________                       __________________________________
Tenant                                                          Date                       Tenant                                                          Date

__________________________________                       __________________________________
Agent                                                            Date                      Agent                                                           Date