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<br />....,.I'- <br /> <br />Sample Disclosure Format for Target Housing Sales <br />Disclosure of Information on Lead-Based Paint and Lead-Based Paint Hazards <br /> <br />Lead Warning Statement <br />Every purchaser of any interest in residential real property on which a residential dwelling was built prior to 1978 <br />is notified that such property may present exposure to lead from lead-based paint that may place young children <br />at risk of developing lead poisoning. Lead poisoning in young children may produce pennanent neurological <br />damage, including leaming disabilities, reduced intelligence quotient, behavioral problems, and impaired memory. <br />Lead poisoning also poses a particular risk to pregnant WOmen. The seller of any interest in residential real property <br />is required to provide the buyer with any infonnation on lead-based paint hazards ffl)m risk assessments or <br />inspections in the seller's possession and notify the buyer of any known lead-basedpaint hazards. A risk <br />assessment or inspection for possible lead-based paint hazards is recommended priOr to purchase. <br /> <br />Seller's Disclosure (initial) <br />_ (a) Presence of lead-based paint andlor lead-based paint hazards (check one below): <br /> <br />o Known lead-based paint and/odead-based paint hazards are present in the housing (explain). <br /> <br />o <br /> <br />Seller has no knowledge of lead-based paint andlor lead-based paint hazards in the housing. <br /> <br />_(b) <br />o <br /> <br />Records and reports available to the seller (check one below): <br /> <br />Seller has provided the punbaser with all available records ancteports pertaining to lead-based paint <br />andlor lead-based paint hazards in the hosing (list documents below). <br /> <br />o Selle~ has no reports or re:ords pertaining to lead~based painlandlor lead-based paint hazards in the <br />housing.' . <br /> <br />Purchaser's Acknowledgment (initial) . <br />_ (c) Purchaser has received copies of all information listed above. <br />_ (d) Purchaser has received the pamphlelProtect Your Family from Lead in Your Home. <br />_ (e) Purchaser has (check one below): <br /> <br />o Received a 1O-day opportunity (or mutually agreed upon period) to conduct a risk assessmentro <br />inspection for the presence of lead-based paint andlor lead-based paint hazards; or <br /> <br />o Waived the opportunity to conduct a ri$k assessment or inspectioiDr the presence of lead-based paint <br />andlor lead-based paint hazards. <br /> <br />Agenfs Acknowledgment (initial) <br />_ (f) Agent has informed the seller of the seller's obligations under 42l1ll.C. 4852(d) and is aware of hislher <br />responsibility to ensure compliance. <br /> <br />Certification of Accuracy <br />The following parties have reviewed the information above and certify, to the best of their knowledge. thatEth <br />information prcwided by the signatory is true and accurate. <br /> <br />Seller <br /> <br />Date <br /> <br />Seller <br /> <br />Date <br /> <br />gent <br /> <br />Date <br /> <br />Agent <br /> <br />Date <br /> <br />Purchaser <br /> <br />Date <br /> <br />Purchaser <br /> <br />Date <br />