DISCLOSURE OF INFORMATION ON LEAD-BASED PAINT
(For homes built before 1978)
Disclosure of information on lead-based paint concerning the property at ______________________________
________________________________________________________________________________________
Owner Affidavit
o ______ (Initial) The above addressed home WAS built before 1978 and therefore the following
information is required by law and APPLICABLE.
o ______ (Initial) The above addressed home WAS NOT built before 1978 and therefore the following
information is NOT required by law and NOT APPLICABLE.
If the Property was built before 1978 complete the following. If the Property was built after 1978 you may
skip the remainder of this document.
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. Before renting pre-1978 housing, lessors (Landlords) must disclose the presence of known lead-based
paint and/or lead-based paint hazards in the dwelling. Lessees (Tenants) must also receive a federally
approved pamphlet on lead poisoning prevention.
Owner Disclosure
1. ______ (Initial) Presence of lead-based paint and/or lead-based paint hazards. (Check (a) or (b)).
o (a) Owner knows of the following lead-based paint and/or lead-based paint hazards in the Property:
__________________________________________________________________________________!
__________________________________________________________________________________!
o (b) Owner has no knowledge of lead-based paint and/or lead-based paint hazards in the Property.
2. ______ (Initial) Records and reports available to Owner. (Check (a) or (b)).
o (a) Owner has provided Tenant with all available records and reports pertaining to lead-based paint
and/or lead-based paint hazards in the Property which are listed here: __________________________
__________________________________________________________________________________
o (b) Owner has no reports or records pertaining to lead-based paint and/or lead-based paint hazards in
the Property.
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