Disclosure Of Information On Lead-Based Paint And/or Lead-Based Paint Hazards printable pdf download

LEAD BASED PAINT ADDENDUM for ______________________________, Ithaca, NY 14850 2017-18

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 known 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

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

(i)

Known lead-based paint and/or lead-based paint hazards are present in the housing

(disclose below any additional information available, such as the basis for the determination that

lead-based paint or lead-based paint hazards exist in the housing, their location, and the condition

of the painted surfaces).

______________________________________________________________________________

(ii)

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 (i) or (ii) below):

(i)

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).

_________________________________________________________________________________

(ii)

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)N/A 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. 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.

Lessee:

Date:

Lessee:

Date:

_____________________________________

_______________________________________

_____________________________________

_______________________________________

_____________________________________

_______________________________________

_____________________________________

_______________________________________

_____________________________________

_______________________________________

_____________________________________

_______________________________________

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Agent: ____________________________ Date: ________

Disclosure Of Information On Lead-Based Paint And/or Lead-Based Paint Hazards

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