AOA Form No. 134 (Rev. 07/10) - Copyright 2006 - Apartment Owners Association of California Inc. - www.aoausa.com
▪ San Fernando Valley (818) 988-9200 ▪ Los Angeles (323) 937-8811 ▪ Long Beach (562) 597-2422 ▪ Garden Grove (714) 539-6000 ▪ San Diego (619) 280-7007 ▪ Northern California (510) 769-7521
LEAD BASED PAINT DISCLOSURE
(Disclosure of Information on Lead-based Paint and 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 lead-based paint hazards in the dwelling. Tenants
must also receive a Federally approved pamphlet on lead poisoning prevention.
Lessor’s Disclosure (initial)
_____(a) Presence of lead-based paint 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.
_____(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 (initial)
_____(c) Lessee has received copies of all information listed above
_____(d) Lessee has received the pamphlet Protect Your Family from Lead in Your Home
Agent’s Acknowledgment (initial)
_____ (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
The following parties have reviewed the information above and certify, to the best of their knowledge,
that the information provided by the signatory is true and accurate.
_____________________________________ ___________________________________
Lessor Date Lessor Date
_____________________________________ ___________________________________
Lessee Date Lessee Date
_____________________________________ ___________________________________
Agent Date Agent Date
