Sample Disclosure Format for Target Housing Sales 
Disclosure of Information on Lead-Based Paint and/or Lead-Based Paint Hazards for Sales 
Property Address: 
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 [ Seller should initial both (a) and (b) ]. 
_(a) Presence of lead-based paint and/or lead-based paint hazards (check one below): 
Known lead-based paint and/or lead-based paint hazards are present in the housing (explain). 
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 one below): 
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). 
Seller has no reports or records pertaining to lead-based paint and/or lead-based 
paint hazards in the housing. 
Purchaser’s Acknowledgment [ Purchaser should initial (c), (d) and (e) ]. 
_(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): 
Received a 10-day opportunity (or mutually agreed upon period) to conduct a risk assessment or 
inspection for the presence of lead-based paint and/or lead-based paint hazards; or 
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 [ Seller’s Agent should initial (f) ]. 
_(f) Agent has informed the seller of the seller’s obligations under 42 U.S.C. 4852(d) and is aware of 
_ his/her responsibility to ensure compliance. _ 
Certification of Accuracy [ Purchaser should be the last person to sign and date this form ]. 
The following parties have reviewed the information above and certify, to the best of their knowledge, that 
the information they have provided by the signatory is true and accurate. 
Seller 
Date 
Purchaser 
Date 
Seller 
Date 
Purchaser 
Date 
Seller’s Agent 
Date 
Purchaser’s Agent 
Date 
Reporting 
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