DISCLOSURE OF INFORMATION ON LEAD-BASED PAINT AND/OR LEAD-BASED 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:
Presence of lead-based paint and/or lead-based paint hazards (check (1) or (2) below):
[   ] Known lead-based paint and/or related hazards are present in the housing (explain).
______________________________________________________________________________________________________________________________________________________
[   ] Lessor has no knowledge of lead-based paint and/or related hazards in the housing.
Records and reports available to the lessor (check (1) or (2) 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 records concerning lead-based paint and/or related hazards in the housing.
Lessee’s Acknowledgement: (initial)
_____ Lessee has received copies of all information listed above.
_____ Lessee has received the pamphlet Protect Your Family from Lead in Your Home.
Agent’s Acknowledgement: (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 they have provided is true and accurate.
__________________________  _______________  __________________________  _______________
Lessor				 Date		      Lessor		 	       Date
__________________________  _______________  __________________________  _______________
Lessee				 Date		      Lessee		 	       Date
__________________________  _______________  __________________________  _______________
Agent				 Date		      Agent		 	       Date