Lead-Based Paint Disclosure Form
Lead Warning Statement
Every property built before 1978 may contain lead-based paint which may place young children and pregnant women at risk of developing lead poisoning. Before renting pre-1978 property, seller must provide the purchaser any information about lead-based paint hazards according to risk assessments or inspections. This assessment and inspections is recomended to be done before the purchase. Purchaser must also receive a federally approved pamphlet on lead poisoning prevention.

Disclosure of Lessor/Seller
Presence of lead-based paint and/or lead-based paint hazards
Known lead-based paint and/or lead-based paint hazards are present in the housing Seller has no knowledge of lead-based paint and/or lead-based paint hazards in the housing
Please Explain
Records and reports available to the seller
Seller has provided the purchaser with all available records and reports pertaining to lead-based paint and/or lead-based paint hazards in the housing Seller has no reports or records pertaining to lead-based paint and/or lead-based painthazards in the housing.
Please upload records or reports
Cancelof

Acknowledgment of Purchaser
Purchaser has
Received copies of all information listed above. Received the pamphlet Protect Your Family from Lead in Your Home.
Purchaser has
received a 10-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 waived the opportunity to conduct a risk assessment or inspection for the presence oflead-based paint and/or lead-based paint hazards.

Acknowledgment of Agent
Agent has
Informed the seller of the seller’s obligations under 42 U.S.C. 4852(d) and is aware of his/her responsibility to ensure compliance.

Certification of Accuracy
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.
Date
Month Day Year
Date
Seller Name
First Name Last Name
Seller Signature
Clear
Purchaser Name
First Name Last Name
Purchaser Signature
Clear
Agent Name
First Name Last Name
Agent Signature
Clear
Should be Empty:

Lead-Based Paint Disclosure Form