Fillable Printable Illinois Lead Based Paint Disclosure Form

Illinois Lead Based Paint Disclosure Form

ILLINOIS ASSOCIATION OF REALTORS

PRE-1978 HOUSING RENTAL AND LEASES DISCLOSURE OF INFORMATION

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 (initial)

_________(a) Presence of lead-based paint and/or lead-based paint hazards (check one below):



nown lead-based paint and/or lead-based paint hazards are present in the housing (explain): K

_________________________________________________________________________



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 one below):



Lessor has provided the lessee with all available records and reports pertaining to lead-

based paint and/or lead-based hazards in the housing (list documents below):

_________________________________________________________________________

___________________________________________________________________________



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. 4852 d 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 / / Lessee ______________________ Date / /

Agent ________________________ Date / / Agent _______________________ Date / /

Property

ddress:_______________________________________________________________________________

orm 421 Revised 10/96 (This disclosure form should be attached to the Lease)