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'-' ~ Sample Disclosure Format for Target Housing Sales Disclosure of Information on Lead-Based Paint and Lead-Based Paint Hazards Lead 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 leaming disabilities, reduced intelligence quotient, behavioral problems, and impaired memory. Lead poisoning also poses a particular risk 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 t'i't5m 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 for possible lead-based paint hazards is recommended priOr to purchase. Seller's Disclosure (initial) (a) Presence of lead-based paint and/or lead-based paint hazards (check one below): o Known lead-based paint and/or lead-based paint hazards are present in the housing (explain). o Seller has no knowledge of lead-based paint and/or lead-based paint hazards in the housing. (b) o Records and reports available to the seller (check one below): Seller has provided the punbaser with all available records ancteports pertaining to lead-based paint and/or lead-based paint hazards in the hosing (list documents below). o Seller has no reports or rlE(lrds pertaining to lead~based painland/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 Fami/y from Lead in Your Home. (e) Purchaser has (check one below): o Received a 1O-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 o Waived the opportunity to conduct a ri$k assessment or inspectioiDr the presence of lead-based paint and/or lead-based paint hazards. Agent's Acknowledgment (initial) _ (f) Agent has informed the seller of the seller's obligations under 42 IS.C. 4852(d) and is aware of hislher responsibility to ensure compliance. Certification of Accuracy The following parties have reviewed the information above and certify. to the best of their knowledge. thatElh information prOlided by the signatory is true and accurate. SeUer Date Seller Date gent Date Agent Date Purchaser Date Purchaser Date 41j/ICI-I/TIe-,VT 2 p, - - I J~