ICR Attachment 6: Lessor's Disclosure of Information on Lead-Based Paint and/or Lead-Based Paint Hazards (Sample Form)

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. Lessees 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 (i) or (ii) below):
(i) ______ Known lead-based paint and/or lead-based paint hazards are present in the housing
(explain).
_______________________________________________________________________________________
_______________________________________________________________________________________
(ii) _____ 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 (i) or (ii) below):
(i) ______ 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).
_______________________________________________________________________________________
_______________________________________________________________________________________
(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)
(c) ________ Lessee has received copies of all information listed above.
(d) ________ Lessee has received the pamphlet Protect Your Family from Lead in Your Home.
Agent’s Acknowledgment (initial)
(e) ________ 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
__________________________________________________
Lessee
Date
__________________________________________________
Agent
Date

__________________________________________________
Lessor
Date
__________________________________________________
Lessee
Date
__________________________________________________
Agent
Date