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<br />'-' <br /> <br />..." <br /> <br />Sample Disclosure Format for Target Housing Rentals and Leases <br />Disclosure of Information on Lead-Based Paint and Lead-Based Paint Hazards <br /> <br /> <br />Lead Warning Statement <br />Housing built before 1978 may contain lead-based paint. Lead from paint, paint chips, and dust can <br />pose health hazards if not taken care of properly. Lead exposure is especially",fJarmful to young <br />children and pregnant women. Before renting pre-1978 housing, landlords must disclose the <br />presence of known lead-based paint and lead-based paint hazards in the dwelling. Tenants must <br />also receive a Federally approved pamphlet on lead poisoning prevention. <br /> <br />Lessor's Disclosure (initial) <br />~ (a) Presence of lead-based paint or lead-based paint hazards (check one below): <br /> <br />o Known lead-based paint andlor lead-based paint hazards are present in the housg, <br />(explain). <br /> <br />o <br /> <br />Lessor has no knowledge of lead-based paint anellor lead-based paint hazards inth <br />housing. <br /> <br />_(b) <br />o <br /> <br />Records and reports available to the lessor (check one below): <br /> <br />Lessor has provided the lessee with all.ailable recordsar.d reports pertaining to lead- <br />based paint and/or lead-based paint hazards in the housing (list documents below). <br /> <br />o <br /> <br />Lessor has no reports or records pertaining to lead-based paint and/or lead-base <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 Your Family from Lead in Your Home. <br /> <br />Agenfs Acknowledgment (initial) <br />(e) Agent has irformed the lessor of the lessor's obligations under 42 U.S.C. 4852(d) and <br />is aware of hislher responsibility to ensure compliance. <br /> <br />Certification of Accuracy <br />The following parties have reviewed the information above and certify, tthe best of their knowledge, <br />that the information provided by the signatory is true and accurate. <br /> <br />A-1tN::~ 2 p~ \ ~ L <br />