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By law, if you are a landlord or selling a premises, you must provide this form to notify the purchaser or new tenant if there is any lead based paint used on the premises.
qwertyuiopasdfghjklzxcvbnmqwertyui opasdfghjklzxcvbnmqwertyuiopasdfgh jklzxcvbnmqwertyuiopasdfghjklzxcvb RESIDENTIAL DISCLOSURE OF nmqwertyuiopasdfghjklzxcvbnmqwer INFORMATION ON LEAD-BASED PAINTOR LEAD-BASED PAINT tyuiopasdfghjklzxcvbnmqwertyuiopas HAZARDS ON PRE-1978 HOUSING dfghjklzxcvbnmqwertyuiopasdfghjklzx [Pick the date] cvbnmqwertyuiopasdfghjklzxcvbnmq wertyuiopasdfghjklzxcvbnmqwertyuio pasdfghjklzxcvbnmqwertyuiopasdfghj klzxcvbnmqwertyuiopasdfghjklzxcvbn mqwertyuiopasdfghjklzxcvbnmqwerty uiopasdfghjklzxcvbnmqwertyuiopasdf ghjklzxcvbnmqwertyuiopasdfghjklzxc vbnmqwertyuiopasdfghjklzxcvbnmrty uiopasdfghjklzxcvbnmqwertyuiopasdf ghjklzxcvbnmqwertyuiopasdfghjklzxc vbnmqwertyuiopasdfghjklzxcvbnmqw ertyuiopasdfghjklzxcvbnmqwertyuiop RESIDENTIAL DISCLOSURE OF INFORMATION ON LEAD-BASED PAINT OR LEAD-BASED PAINT HAZARDS ON PRE-1978 HOUSING 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 managed properly. Lead exposure is especially harmful to young children and pregnant women. Disclosure (a) Presence of lead-based paint and/or lead-based paint hazards (Check (1) or (2) below): (1) _____ Known lead-based paint and/or lead-based paint hazards are present in the housing (explain): ______________________________________________ (2) ____ Landlord has no knowledge of lead-based paint and/or lead-based paint hazards in the housing. (b) Records and reports available to the landlord (Check (1) or (2) below): (b1) _____ Landlord has provided the Tenant with all available records and reports pertaining to lead-based paint and/or lead-based paint hazards in the housing (list documents): ______________________________________________ (b2)____ Landlord has no reports or records pertaining to lead-based paint and/or lead- based paint hazards in the housing. © Copyright 2011 Docstoc Inc. registered document proprietary, copy not 2 Tenant's Acknowledgment (initial) (3) _____ Tenant has received copies of all information listed above. (4) _____ Tenant has received the pamphlet, Protect Your Family from Lead in Your Home. 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. ____________________ Date: ___________ SUBSCRIBED TO AND SWORN TO before me this ___ day of_______________, 20____. ______________________ NOTARY PUBLIC My Commission Expires: _______ NOTICE The information in this document is designed to provide an outline that you can follow when formulating business or personal plans. Due to the variances of many local, city, county and state laws, we recommend that you seek professional legal counseling before entering into any contract or agreement. © Copyright 2011 Docstoc Inc. registered document proprietary, copy not 3
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