Lead-Based Paint Acknowledgement

LEAD-BASED PAINT DOCUMENT

RESIDENTIAL LEASE DISCLOSURE OF INFORMATION ON LEAD-BASED PAINT 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, landlords must disclose the presence of known lead-based paint and/or lead-based paint hazards in the dwelling. Tenants must also receive a federally approved pamphlet on lead poisoning prevention.

Landlord's Disclosure

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

Known lead-based paint and/or lead-based paint hazards are present in the housing (explain):

Landlord has no knowledge of lead-based paint and/or lead-based paint hazards in the housing.

(b) Records and reports available to the landlord (Check (i) or (ii) below):

Landlord has provided the tenant with all available records and reports pertaining to lead-based paint and/or lead-based paint hazards in the housing (list documents):

Landlord has no reports or records pertaining to lead-based paint and/or lead-based paint hazards in the housing.

Tenant's Acknowledgment (initial)

Tenant Acknowedgement (via checked box)

Tenant has received copies of all information listed above.

Tenant has received the pamphlet Protect Your Family from Lead in Your Home.

Certification of Accuracy

The following parties have reviewed the lead-based paint information outlined herein and certify, to the best of their knowledge, that the information they have provided is true and accurate.

Landlord Signature

Tenant's Signature

CINLibrary 0118993.0574487 2083598v1

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