FORM 420 (05/2019) COPYRIGHT ILLINOIS REALTORS
®
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ILLINOIS REALTORS
®
DISCLOSURE OF INFORMATION AND ACKNOWLEDGEMENT
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.
Property Address:
Seller's Disclosure (initial)
______ (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 (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 one below):
Received a 10-day opportunity (or mutually agreed upon period) to conduct a risk assessment or inspection
of the presence of lead-based paint 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 (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 _____________ Purchaser ___________________ Date _____________
Seller _______________________ Date _____________ Purchaser ___________________ Date _____________
Agent _______________________ Date _____________ Agent ______________________ Date _____________
(This disclosure form should be attached to the Contract to Purchase.)
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