This disclosure is used to warn a tenant 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
[Lease]
Lessor’s Name and Address:
Lessee’s Name and Address:
Description of Property:
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 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
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(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, the location of the lead-based paint and/or lead-based paint hazards, and the condition of the painted surfaces]. |
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(ii) |
Lessor has no knowledge of lead-based paint and/or lead-based paint hazards in the housing. |
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(b) |
Records and reports available to Lessor (check (i) or (ii) below): |
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(i) |
Lessor has provided Lessee 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) |
Lessor has no reports or records pertaining to lead-based paint and/or lead-based paint hazards in the housing. |
Lessee’s Acknowledgment (initial)
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(c) |
Lessee has received copies of all information listed above. |
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(d) |
Lessee has received the lead hazard information pamphlet described in 15 U.S.C. section 2686. |
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Agent’s Acknowledgment (initial)
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(e) |
Agent has informed Lessor of Lessor’s obligations under 42 U.S.C. section 4852d and is aware of his/her responsibility to ensure compliance. |
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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
Lessee Date
Agent Date