Fillable Printable Maine Lead Based Paint Disclosure Form
Fillable Printable Maine Lead Based Paint Disclosure Form
Maine Lead Based Paint Disclosure Form
Maine Health & Human Services, P ublic Health 1 9/22/2005
Property Lease Form
Residential Real Property Disc losure Statement
MAINE WARNING: LEAD-BASED PAINT HAZARDS
Any residence built before 1978 may contain lead sufficient to poison
children and sometimes adults. Lead poisoning poses a particularrisk if
you are pregnant ormay become pregnant. Lead poisoning in young
children may produce permanent neurological damage, including
learning disabilities, a reduced intelligence quotient (IQ), impaired
memory and behavioral problems such as attention deficit hyperactive
disorder and a propensity for violence.
Every tenant or lessor of any interest in residential real property on which a
residential dwelling was built prior to 1978 is notified that such propertymay
present exposure to lead from lead-based paint that may place young children at
risk of developing lead poisoning. The landlord or other lessor of anyinterest in
real property isrequired to provide the tenant or lessee with any information on
lead-based paint hazards from risk assessments or inspections in the landlord's or
lessor's possession and notify the tenant or lessee of any known lead-based paint
hazards.
The only way to know with certainty whether lead-based paint hazards
are present on the property is to test the property for the presence of lead.
Acknowledgement of State Disclosure Statement.
The signature below acknowledges that the lessor or potential lessor has disclosed to me
information about lead-based paint hazards as required by 22 M.R.S.A. Section 1328. This
acknowledgement does not constitute a waiver of any rights.
______________________________ __________________________________
Lessor Signature Date Lessee Signature Date
_______________________________ __________________________________
Lessor Name printed Lessee Name printed
_______________________________ __________________________________
Lessor Signature Date Lessee Signature Date
_______________________________ __________________________________
Lessor Name printed Lessee Name printed
Maine Health & Human Services, P ublic Health 2 9/22/2005
Property Lease Form
Ack n owledgement of federal disc losure of inf ormation
on Le ad-Bas ed Pain t and/or L e ad-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 Acknowledgement (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 Acknowledgement (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 Lessor Date
____________________________________ _________________________________________
Lessee Date Lessee Date
____________________________________ _________________________________________
Agent Date Agent Date
