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Sample Disclosure Format for Target Housing Rentals and Leases <br />Disclosure of Information on Lead-Based Paint and Lead-Based Paint Hazards <br /> <br />Lead Warning Statement <br />Housing built before 1978 may contain lead-based paint. Lead from pain~ paint chips, and dust can <br />pose health hazards ff not taken care of properly. Lead exposure is especiall~harmful to young <br />children and pregnant women. Before ranting pre-1978 housing, landlords must disclose the <br />presence of known lead-based paint and lead-based paint hazards in the dwelling. Tenants mum <br />also receive a Federally approved pamphlet on lead poisoning preven§on. <br /> <br />Lessor's Disclosure (initial) <br /> <br />~ (a) Presence of lead-based paint or lead-based paint hazards (check one below): <br /> [~ Known lead'based pal~t and/or lead-based paint hazards are present in the hous~ <br /> (explain). <br /> <br />Lessor has no knowledge of lead-based paint and/or lead-based paint hazardsin <br />housing. <br /> <br />~ (b) Records and reports available to the lessor (check one below): <br /> <br />~"~ Lessor has provided the lessee with all aailable records.and reports pertaining to lead- <br /> based paint and/or lead-based paint haz.ards in the housing (list documents below). <br /> <br /> [~ Lessor has no reports or records pertaining to lead-based paint and/or lead-bas~ <br /> paint hazards in the housing. ' ' <br /> <br />Lessee's Acknowledgment (initial) <br /> (c) Lessee has received copies of all information listed above. <br />__ (d) Lessee has received the pamphletProtect ¥our Family from Leadin ¥ourHome. <br /> <br />Agent's Acknowledgment (initial) <br /> (e) ~(lent has irformed the lessor.of the lessor's obr~ations under 42 U.S.C. 4852(d) and <br /> is aware of his/her responsibility to ensure compliance. <br /> <br />Ce,t;l~cafion of Accuracy <br />The following parties have reviewed the information above and cerlify, tthe best of their knowledge, <br />that the information provided by the signatory is true and accurate. <br /> <br />Lessor Date Lessor Date <br />Lessee Date Lessee Date <br />Agent Date Agent Date <br /> <br /> <br />