California Lead Based Paint Disclosure Form

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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 Lessor Date

Lessee Date Lessee Date

Agent Date Agent Date

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Fillable Printable California Lead Based Paint Disclosure Form