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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 property. Lead exposure is especialtharmful to young children and pregnant women. Before renting pre -1978 housing, landlords must disclose 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 hou* (explain). Lessor has no knowledge of lead-based paint and/or lead-based paint hazards in th 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. Agent's Acknowledgment (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, 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 fi'rrACkW�- Z F% I ,� 7--