RESIDENTIAL DISCLOSURE OF
INFORMATION ON LEAD-BASED
PAINTOR LEAD-BASED PAINT
HAZARDS ON PRE-1978 HOUSING
[Pick the date]
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.
(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
(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
(b2)____ Landlord has no reports or records pertaining to lead-based paint and/or lead-
based paint hazards in the housing.
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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.
SUBSCRIBED TO AND SWORN TO before me this ___ day of_______________, 20____.
My Commission Expires: _______
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.
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