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<br />I . <br /> <br />Sample Disclosure Format for Target Housing Rentals and Leases <br />Disclosure of Information on Lead-Based Paint and Lead-Based Paint Hazards <br /> <br />Lead Warning Statement <br />Housing built before 1978 may contain lead-based paint. Lead from paint, paint chips, and dust can <br />pose health hazards if not taken care of property. Lead exposure is especiallY"þarmful to young <br />children and pregnant women, Before renting pre-1Y78 housing, landlords must disclose the <br />presence of known lead-based paint and lead-based paint hazards in the dwelling. Tenants must <br />also receive a Federally approved pamphlet on lead poisoning prevention. <br /> <br />Lessor's Disclosure (initial) <br />:...-- (a) Presence of lead-based paint or lead-based paint hazards (check one below): <br /> <br />0 Known lea~based paint and/or lead-based þaint hazards are present in the housiP <br />(explain). <br /> <br />0 Lessor has no knowledge of lead-based paint and/or lead-based paint hazards in Ita <br />housing. . <br /> <br />- (b) Records and reports available to the lessor (check one below): <br /> <br />0 Lessor has provided the Jessee with all aailable recordsar.d reports pertàining to lead- <br />based paint and/or lead-based paint haz~m:ls in the housing (list documents below). <br /> <br />0 Lessor has no reports or records pertaining to lead-based paint and/or lead-base <br />paint hazards in the housing, <br /> <br />Lessee's Acknowledgment (initial) <br />- (c) Lessee has received copies of all information listed above. <br />- (d) Lessee has received the pamphletPlOtect Your Family from Lead in Your Home. <br /> <br />Agenfs Acknowledgment (initial) <br />- (e) Agent has irformed the lessor of the lessor's obligations under 42 U,S.C, 4852(d) and <br />is aware of hislher responsibility to ensure compliance. <br /> <br />Certification of Accuracy <br />The following parties have reviewed the information above and certify, une best of their knowledge. <br />that the information provided by the signatory is true and accurate. <br /> <br />Lessór Date Lessor <br />Lessee Date Lessee <br />Agent Date Agent <br /> <br />Date <br /> <br />Date <br /> <br />Date <br /> <br />It <br /> <br />kn~~ 2.. ~\~L <br />