This Disclosure of Information on Lead-Based Paint and/or Lead-Based Paint Hazards
is intended to be used by the seller or lessor of any residential property in order to be in
compliance with governing federal laws pertaining to lead-based paint hazards. This
document contains the necessary information regarding the presence of lead-based
paint on the property and the risks associated with lead exposure, as required by law.
This form should be used by lessors and sellers of real property.
DISCLOSURE OF INFORMATION ON LEAD-BASED PAINT AND/OR LEAD-BASED
Lead Warning Statement
Every purchaser of any interest in residential real property on which a residential dwelling was built
prior to 1978, as per Section 4852(d), Chapter 63A, Title 42 of 2010 United States Code 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 learning 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 from 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.
1. Lessor’s Disclosure
a. Presence of lead-based paint and/or lead-based paint hazards
[Instruction: Select the clause by inserting “X”]
i. _____________ Known lead-based paint and/or lead-based paint hazards are present
in the housing (explain)
___________. As per Section __, Chapter __, Title __ of 20__ ____________________
ii. _____________ Lessor has no knowledge of lead-based paint and/or lead-based paint
hazards in the housing.
b. Records and reports available to the Lessor [Instruction: Select the clause by inserting
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i. _____________ Lessor has provided the Lessee with all available records and reports
pertaining to lead-based paint and/or lead-based paint hazards in the housing (list
ii. _____________ Lessor has no reports or records pertaining to lead-based paint and/or
lead-based paint hazards in the housing.
2. Lessee's Acknowledgment (initial)
a. _____________ Lessee has received copies of all information listed above.
b. _____________ Lessee has received the pamphlet Protect Your Family from Lead in Your
c. Lessee has [Instruction: Select the clause by inserting “X”] :
i. _____________ received ___________ (___) [Fourteen (14)] days [Comment: these
numbers are not provided by the law, but can be any number the user chooses]
opportunity (or mutually agreed upon period) to conduct a risk assessment or inspection
for the presence of lead-based paint and/or lead-based paint hazards; or
ii. _____________ waived the opportunity to conduct a risk assessment or inspection for the
presence of lead-based paint and/or lead-based paint hazards.
3. Agent's Acknowledgment (initial)
_____________ 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.
4. Certification of Accuracy
The following parties have reviewed the information above and certify, to the best of their
knowledge, that the information they have provided is true and accurate.
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