ICR Attachment 5: Seller'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
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):
(i) ______ Known lead-based paint and/or lead-based paint hazards are present in the housing
(explain).
_______________________________________________________________________________________
(ii) _____ Seller has no knowledge of lead-based paint and/or lead-based paint hazards in the housing.
(b) Records and reports available to the seller (check (i) or (ii) below):
(i) ______ Seller has provided the purchaser with all available records and reports pertaining to leadbased paint and/or lead-based paint hazards in the housing (list documents below).
_______________________________________________________________________________________
(ii) _____ Seller has no reports or records pertaining to lead-based paint and/or lead-based paint
hazards in the housing.
Purchaser’s Acknowledgment (initial)
(c) ________ Purchaser has received copies of all information listed above.
(d) ________ Purchaser has received the pamphlet Protect Your Family from Lead in Your Home.
(e) Purchaser has (check (i) or (ii) below):
(i) _____ 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; or
(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 the seller of the seller’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.

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Seller
Date
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Purchaser
Date
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Agent
Date

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Seller
Date
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Purchaser
Date
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Agent
Date