Property Address:________________________________ Date:__________

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. Lessee 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 one below):

_____ Known lead-based paint and/or lead-based paint hazards are present in the housing (explain). _______________________________

______ 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 one below):

_____ 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).

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

Lessee’s Acknowledgement

(c) ____ Lessee has received copies of all information listed above.

(d) ____ Lessee has received the pamphlet Protect Your Family from Lead In Your Home

 

Lessee ________________ Date ______ Lessor ________________ Date _____

Lessee ________________ Date ______ Lessor ________________ Date _____