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 of Atlanta, 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 federally approved 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 Name Owner/Landlord Signature Date

Participant Print Name Participant Signature Date

Agent Print Name Agent Signature Date

Owner/Landlord Name

Participant Name Participant SSN

Property Name Unit Address

City Zip

Owner/Landlord Phone Number

State

(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 responsibility to 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)

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)