LEAD-BASED PAINT AND/OR LEAD-BASED
PAINT HAZARDS
DISCLOSURE OF INFORMATION AND
ACKNOWLEDGEMENT
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 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.
Seller’s Disclosure (Initial)
_____(a) Presence
of lead-based paint and/or lead based paint hazards (check one below):
q Known
lead-based paint and/or lead-based paint hazards are present in the
housing
(explain):_____________________________________________
q Seller
has no knowledge of lead-based paint and/or lead-based paint hazards in the
housing.
_____(b) Records and Reports available to the lessor (check one
below):
q Seller
has provided the purchaser with all available records and reports
pertaining to lead-based paint and/or
lead-based paint hazards in the housing
(list documents
below):___________________________________________
q Seller
has no reports or records pertaining to lead-based paint and/or
lead-based paint hazards in the
housing.
Purchaser’s Acknowledgement (Initial)
_____ (c) Purchaser has received copies of all information
listed above.
_____(d) Purchaser has received the pamphlet Protect Your Family
From Lead In Your Home.
_____(e) Purchaser has (check one below):
q Received
a 10-day opportunity (or mutually agreed upon period) to conduct
a
risk assessment or inspection of the presence of lead-based paint or lead-based
paint
hazards.
q Waived
the opportunity to conduct a risk assessment or inspection for the
presence of lead-based paint and/or
lead-based paint hazards.
Agent’s Acknowledgement (Initial)
_____(f) Agent has informed the seller of the seller’s obligations under 42 U.S.C. 4852d
and is aware of his/her responsibility
to ensure compliance.
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.
__________________________ __________________________
Buyer Date Buyer Date
__________________________ __________________________
Seller Date Seller Date
__________________________ __________________________ Agent Date Agent Date