Disclosure of Information on 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 Description (Address) _________________________________________________________
City, State, Zip _________________________________________________________
Seller’s Disclosure
(A) Presence of lead-based paint and/or lead-based paint hazards (check (1) or (2) below):
(1) ______ Known lead-based paint and/or lead-based paint hazards are present in the housing
Explain: _______________________________________________________________________________
(2) ______ 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 (1) or (2) below):
(1) ______ 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: ________________________________________________________________________
(2) ______ Seller has no reports or records pertaining to lead-based paint and/or lead-based paint hazards in the
housing.
Purchaser’s Acknowledgment
(initial below)
(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 (1) or (2) below):
(1) ______ 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
(2) ______ 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 below)
(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.
LREC 01/01/05 1 of 2
