Disclosure of Information on Lead-Based Paint and/or Lead-Based Paint Hazards 

Lead Warning Statement 

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 

(a) Presence of lead-based paint and/or lead-based paint hazards (check (i) or (ii) below): 

(i) ______Known lead-based paint and/or lead-based paint hazards are present in the housing 

(explain). 

________________________________________________________________

(ii) _____ Seller has no knowledge of lead-based paint and/or lead-based paint hazards in the housing. 

(b) Records and reports available to the seller (check (i) or (ii) below): 

(i) ______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). 

___________________________________________________________________

(ii) _____ Seller has no reports or records pertaining to lead-based paint and/or lead-based paint 

hazards in the housing. 

Purchaser’s Acknowledgment(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 (i) or (ii) below): 

(i) _____ received a 10-day opportunity (or mutually agreed upon period) to conduct a risk assess- 

ment 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. 

Agent’s Acknowledgment(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. 

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. 

____________________________________________________________

Seller Date Seller Date 

___________________________________________________________

Purchaser Date Purchaser Date 

___________________________________________________________________ 

Agent Date Agent Date