Lead Based Paint Disclosure Notice
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1Lead-Based Paint Disclosure Notice
Disclosure of Information on Lead-Based Paint
and/or Lead-Based Paint Hazards
Housing Choice Voucher Program
Housing Authority of the City of Atlanta, Georgia
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 hazards in the dwelling. Lessees
must also receive a federally approved pamphlet on lead poisoning prevention. 42 U.S.C. 4582(d)
Owner/Landlord Name
Owner/Landlord Phone Number
Property Name
Unit Address
City
State
Zip
Participant Name
Participant SSN
Owner/Landlord's Disclosure:
Presence of lead-based paint and/or lead-based paint hazards: (Check one below)
(initial)
Known lead-based paint and/or lead-based paint hazards are present in the housing. (Explain)
Owner/Landlord has no knowledge of lead-based paint and/or lead-based paint hazards in housing. (Explain)
Records and reports available to the Owner/Landlord: (Check one below)
(initial)
Owner/Landlord has provided the Participant with all available records and reports pertaining to lead-based
paint and/or lead-based paint hazards in the housing. (List documents)
Owner/Landlord has no records or reports pertaining to lead-based paint and/or lead-based paint hazards in
the housing.
Participant's Acknowledgement:
Participant has received copies of all the information listed above.
(initial)
Participant has received the pamphlet Protect Your Family from Lead in Your Home.
(initial)
Agent's Acknowledgement:
Agent has informed the Owner/Landlord of the Owner/Landlord's obligations under 42 U.S.C. 4852(d) and is aware
of his/her responsibility to ensure compliance.
(initial)
Certificate 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.
Owner/Landlord Print Name
Owner/Landlord Signature
Date
Participant Print Name
Participant Signature
Date
Agent Print Name
Agent Signature
Date
230 John Wesley Dobbs Ave NE
Atlanta, Georgia 30303-2421
Office: 404-892-4700
Fax: 404-685-4896
Previous editions are obsolete
AHA Form 034 (June 2008)
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