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Sample Disclosure Format for Target Housing Rentals and Leases Disclosure of Information on Lead-Based Paint and Lead-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 taken care of propedy. Lead exposure is especiaA~~armful to young children and pregnant women. Before renting pre-1978 housing, landlords must disGose the presence of known lead-based paint and lead-based paint hazards in the dwelling. Tenants must also receive a Federally approved pamphlet on lead poisoning prevention. Lessor's Disclosure (initial) (a) Presence of lead-based paint or lead-based paint hazards (check one below): Known lead-based paint and/or lead-based paint hazards are present in the housgi (explain). Lessor has no knowledge of lead-based paint andlor read-based paint hazards in ~ housing. (b) Records and reports available to the lessor (check one below): Lessor has provided the lessee with all Bailable records and reports pertaining to lead- based paint and/or lead-based paint hazards in the housing (list documents below). Lessor has no reports or records pertaining to lead-based paint and/or lead-bast; paint hazards in the housing. Lessee's Acknowledgment (initial) (c) Lessee has received copies of all information listed above. (d) Lessee has received the pamphletProtect Your Family from Lead in Your Home. Agents Acknowledgment Initial) (e) Agent has irfonned the lessor of the Iesso~s obligations under 42 U.S.C. 4852(d) and is aware of his/her responsibility to ensure compliance. Certification of Accuracy The folbwing parties have reviewed the information above and certify, tthe best of their knowledge, that the information provided by the signatory is true and accurate. Lessor Date Lessor Date Lessee Date Lessee Date Agent Date Agent Date k-rtAC+t~e~.s: z P°l ~ ~ ~