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 particular risk if

you are pregnant or may 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 property may

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 any interest in

real property is required 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)

(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