Fillable Printable Georgia Lead Based Paint Disclosure Form
Fillable Printable Georgia Lead Based Paint Disclosure Form
Georgia Lead Based Paint Disclosure Form
Lead-Based Paint Disclosure Notice
Disclosure of Information on Lead-Based Paint
and/or Lead-Based Paint Hazards
Housing Choice Voucher Program
Housing Authority of the City ofAtlanta, Georgia
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 hazards in the dwelling. Lessees
must also receive a federallyapproved pamphlet on lead poisoning prevention. 42 U.S.C. 4582(d)
Presence of lead-based paint and/or lead-based paint hazards: (Check one below)
Owner/Landlord's Disclosure:
Participant's Acknowledgement:
Agent's Acknowledgement:
Certificate of Accuracy
Records and reports available to the Owner/Landlord: (Check one below)
Owner/Landlord Print NameOwner/Landlord SignatureDate
Participant Print NameParticipant SignatureDate
Agent Print NameAgent SignatureDate
Owner/Landlord Name
Participant NameParticipant SSN
Property NameUnit Address
CityZip
Owner/Landlord Phone Number
State
(initial)
(initial)
Participant has received copies of all the information listed above.
Participant has received the pamphlet Protect Your Family from Lead in Your Home.
Agent has informed the Owner/Landlord of the Owner/Landlord's obligations under 42 U.S.C. 4852(d) and is aware
of his/her responsibilityto ensure compliance.
The following parties have reviewed the information above and certify, to the best of their knowledge, that the information
provided by the signatory is true and accurate.
230 John Wesley Dobbs Ave NE Atlanta, Georgia 30303-2421 Office: 404-892-4700 Fax: 404-685-4896 AHA Form 034 (June 2008)
Previous editions are obsolete
(initial)
(initial)
(initial)
Owner/Landlord has provided the Participant with all available records and reports pertaining to lead-based
paint and/or lead-based paint hazards in the housing. (List documents)
Owner/Landlord has no records or reports pertaining to lead-based paint and/or lead-based paint hazards in
the housing.
Known lead-based paint and/or lead-based paint hazards are present in the housing. (Explain)
Owner/Landlord has no knowledge of lead-based paint and/or lead-based paint hazards in housing. (Explain)
