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Sample Disclosure Format for Target Housing Sales Disclosure of Information on Lead -Based Paint and Lead -Based Paint Hazards Lad Warning Statement Every purchaser 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. Lead poisoning in young children may produce permanent neurological damage, including learning disabilities, reduced intelligence quotient, behavioral problems, and impaired memory. Lead poisoning also poses a parboularnsk to pregnant women. The seller of any interest in residential real property is required to provide the buyer with any information on lead -based paint hazards frg'm risk assessments or inspections in the seller's possession and notify the buyer of any known lead -based paint hazards. A risk assessment or inspection forpossib/e lead -based paint hazards is recommended prior to purchase. Seller's Disclosure (nitiao (a) Presence of lead -based paint and/or lead -based paint hazards (check one below): Known lead -based paint and/ot lead -based paint hazards are present in the housing (explain). rl Seller has no knowledge of lead -based paint and/or lead -based paint hazards in the housing. (b) Records and reports available to the seller (check one below): Seller has provided the purcaser with all available records andreports pertaining to lead -based paint and/or lead -based paint hazards in the hoeing (list documents below). Seller has no reports or rwoords pertaining to lead -based painiand/or lead -based paint hazards in the housing. Purchaser's Acknowledgment (initial) (c) Purchaser has received copies of all information listed above. (d) Purchaser has received the pamphletProtect Your Family from Lead in Your Home. (e) Purchaser has (check one below): Received a 10-day opportunity (or mutually agreed upon period) to conduct a risk assessmentro inspection for the presence of lead -based paint and/or lead -based paint hazards; or Waived the opportunity to conduct a risk assessment or inspectiodgr the presence of lead -based paint and/or lead -based paint hazards. Agent's Acknowledgment (initial) (f) Agent has informed the seller of the sellers obligations under 42 6$.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, thatdh information presided by the signatory is true and accurate. Seller Date Seller Date Went Date Agent Date Purchaser Date Purchaser Date