SAMPLE DISCLOSURE FORM FOR RENTALS AND LEASES - CERTIFICATION BY AGENT 
Disclosure of Information on Lead-Based Paint and/or Lead-Based Paint Hazards 
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 must disclose the 
presence of lead-based paint and/or lead-based paint hazards in the dwelling. Lessees must also 
receive a federally approved pamphlet on lead poisoning prevention. 
Lessor’s Disclosure [ Landlord or agent should initial both (a) and (b) ]. 
£&f (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). 
„ Lessor has no knowledge of lead-based paint and/or lead-based paint hazards in the 
housing. 
S&tf (b) Records and reports available to the lessor (check one below)-. 
Lessor has provided the lessee with all available records and reports pertaining to lead- 
based paint and/or lead-based paint hazards in the housing (list documents below). 
Lessor has no reports or records pertaining to lead-based paint and/or lead-based 
paint hazards in the housing. 
Lessee’s Acknowledgment [ Tenant should initial both (c) and (d) ]. 
33 ' (c) Lessee has received copies of all information listed above. 
33' (d) Lessee has received the pamphlet Protect Your Family from Lead in your Home. 
Agent’s Acknowledgment [ Agent, if not landlord’s direct employee, should initial (e) ]. 
£&f (e) Agent has informed the lessor of the lessor’s obligations under 42 U.S.C. 4852(d) and is 
aware of his/her responsibility to ensure compliance. 
Certification of Accuracy [ Tenant 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. 
Lessor 
Date 
Lessor 
Date 
5334/ ^/e/io/3 _ ■/■//////&£ _ 
Lessee Date Lessee Date 
S&ijt _ ■/■//(9 _ _ 
Agent Date Agent Date 
7 2 
Chapter B 
