This disclosure is used to warn a buyer about potential risks associated with lead-based paint. The form is based on the notice requirements of 40 C.F.R. § 745.113 and the disclosure form suggested by the Department of Housing and Urban Development; the language should not be altered without a review of the applicable regulations. The heading and text of the notice are required by the regulations to be in bold-faced type.
Disclosure of Information on Lead-Based Paint
and/or Lead-Based Paint Hazards
[Sales]
Seller’s Name and Address:
Buyer’s Name and Address:
Description of Property:
Lead Warning Statement
Every purchaser of any interest in residential real property on which a residential dwelling was built prior to 1978 is notified that such property may present exposure to lead from lead-based paint that may place young children at risk of developing lead poisoning. Lead poisoning in young children may produce permanent neurological damage, including learning disabilities, reduced intelligence quotient, behavioral problems, and impaired memory. Lead poisoning also poses a particular risk to pregnant women. The seller of any interest in residential real property is required to provide the buyer with any information on lead-based paint hazards from risk assessments or inspections in the seller’s possession and notify the buyer of any known lead-based paint hazards. A risk assessment or inspection for possible lead-based paint hazards is recommended prior to purchase.
Seller’s Disclosure
(a)Presence of lead-based paint and/or lead-based paint hazards (check (i) or (ii) below):
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(i) |
Known lead-based paint and/or lead-based paint hazards are present in the housing [explain, providing the basis for the determination that lead-based paint and/or lead-based paint hazards exist, its/their location[s] and condition[s], and any additional information about the lead-based paint or lead-based paint hazards (if known)]. |
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(ii) |
Seller has no knowledge of lead-based paint and/or lead-based paint hazards in the housing. |
(b)Records and reports available to Seller (check (i) or (ii) below):
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(i) |
Seller has provided Buyer with all available records and reports pertaining to lead-based paint and/or lead-based paint hazards in the housing (list documents below). |
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(ii) |
Seller has no reports or records pertaining to lead-based paint and/or lead-based paint hazards in the housing. |
Buyer’s Acknowledgment (initial)
____ (c) Buyer has received copies of all information listed above.
____ (d) Buyer has received the lead hazard information pamphlet described in 15 U.S.C. section 2686.
____ (e) Buyer has (check (i) or (ii) below):
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(i) |
received a ten-day opportunity (or mutually agreed upon period) to conduct a risk assessment or inspection for the presence of lead-based paint and/or lead-based paint hazards; or |
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(ii) |
waived the opportunity to conduct a risk assessment or inspection for the presence of lead-based paint and/or lead-based paint hazards. |
Agent’s Acknowledgment (initial)
____ (f) Agent has informed Seller of Seller’s obligations under 42 U.S.C. section 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.
Seller Date
Buyer Date
Agent Date