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Sample Disclosure Format for Target Housing Rentals and Leases <br />Disclosure of Information on Lead -Based Paint and Lead -Based Paint Hazards <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 properly. Lead exposure is especia ftparmful to young <br />children and pregnant women. Before ranting pre -1978 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 />Lessor's Disclosure (initial) <br />(a) Presence of lead-based paint or lead-based paint hazards (check one below): <br />Known lead-based paint and/or lead-based paint hazards are present in the housgr <br />(explain). <br />D Lessor has no knowledge of lead-based paint and/or lead-based paint hazards in th <br />housing. <br />(b) Records and reports available to the lessor (check one below): <br />Lessor has provided the lessee with all t ailable records and reports pertaining to lead- <br />based paint and/or lead-based paint hazards in the housing (list documents below). <br />Lessor has no reports or records pertaining to lead-based paint and/or lead-basb <br />paint hazards in the housing. <br />Lessee's Acknowledgment (initial) <br />(c) Lessee has received copies of all information listed above. <br />(d) Lessee has received the pamphletProtect Your Family from Lead in Your Home. <br />Agents 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 his/her responsibility to ensure compliance. <br />Certification of Accuracy <br />The following parties have reviewed the information above and certify, tthe best of their knowledge, <br />that the information provided by the signatory is true and accurate. <br />Lessor Date Lessor Date <br />Lessee Date Lessee Date <br />Agent Date Agent Date <br />+I <br />A- ACS WLE - Z P°. 149 7— <br />i <br />J <br />�' <br />