Fillable Printable Disclosure of Information on Lead Warning Statement
Fillable Printable Disclosure of Information on Lead Warning Statement
Disclosure of Information on Lead Warning Statement
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 notied 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).
_____________________________________________________________________________
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. 4852(d)
and is
aware of his/her responsibility to ensure compliance.
Certi"cation 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.
_______________________________________________ _______________________________________________
Seller Date Seller
Date
_______________________________________________ _______________________________________________
Purchaser Date Purchaser
Date
_______________________________________________ _______________________________________________
Agent Date Agent
Date
