Lead-Based Paint Disclosure Form Template

This Lead-Based Paint Disclosure Form (“Disclosure”) is made on [Date] in connection with the following transaction:

• Transaction Type: ☐ Sale ☐ Lease

• Property Address: [Property Address]

• City, State, ZIP Code: [City, State, ZIP Code]

• Year Built (if known): [Year]

• Seller / Lessor: [Full Name]

• Buyer / Lessee: [Full Name]

1. Lead Warning Statement

Use the applicable federally required warning statement for the transaction type.

For Sale Transactions:
Insert the federally required lead warning statement applicable to a pre-1978 residential property sale.

For Lease Transactions:
Insert the federally required lead warning statement applicable to a pre-1978 residential housing lease.

2. Seller’s / Lessor’s Disclosure

Initial one option in each subsection.

(a) Presence of lead-based paint and/or lead-based paint hazards

___ (i) Known lead-based paint and/or lead-based paint hazards are present in the housing.
Describe what is known:
[Describe location, condition, prior testing results, or other known information]

___ (ii) Seller / Lessor has no knowledge of lead-based paint and/or lead-based paint hazards in the housing.

(b) Records and reports available to the Seller / Lessor

___ (i) Seller / Lessor has provided all available records and reports pertaining to lead-based paint and/or lead-based paint hazards in the housing.
List documents below:
[Inspection reports, risk assessments, repair records, disclosure reports, other records]

___ (ii) Seller / Lessor has no reports or records pertaining to lead-based paint and/or lead-based paint hazards in the housing.

3. Buyer’s / Lessee’s Acknowledgment

Initial all applicable items.

(c) Receipt of records and reports

___ (i) Buyer / Lessee has received copies of all records and reports listed above.

___ (ii) Buyer / Lessee has not received any records or reports regarding lead-based paint and/or lead-based paint hazards in the housing.

(d) Receipt of pamphlet

___ Buyer / Lessee has received the pamphlet Protect Your Family From Lead in Your Home.

(e) Sale transactions only — inspection opportunity

Complete this section only if the transaction is a sale.

___ (i) Buyer has received a 10-day opportunity, or another mutually agreed written period, to conduct a risk assessment or inspection for the presence of lead-based paint and/or lead-based paint hazards.

___ (ii) Buyer has waived the opportunity to conduct a risk assessment or inspection for the presence of lead-based paint and/or lead-based paint hazards.

4. Agent’s Acknowledgment

Complete if an agent is involved.

___ Seller’s / Lessor’s Agent has informed the Seller / Lessor of the Seller’s / Lessor’s obligations under applicable lead-based paint disclosure law and is aware of the agent’s responsibility to help ensure compliance.

___ Buyer’s / Lessee’s Agent has informed the Seller / Lessor of the Seller’s / Lessor’s obligations under applicable lead-based paint disclosure law and is aware of the agent’s responsibility to help ensure compliance.

5. Certification of Accuracy

The parties below have reviewed the information in this Disclosure and certify, to the best of their knowledge, that the information provided is true and accurate.

6. Signatures

Seller / Lessor

Signature: __________________________
Name: [Full Name]
Date: [Date]

Seller / Lessor (if applicable)

Signature: __________________________
Name: [Full Name]
Date: [Date]

Buyer / Lessee

Signature: __________________________
Name: [Full Name]
Date: [Date]

Buyer / Lessee (if applicable)

Signature: __________________________
Name: [Full Name]
Date: [Date]

Seller’s / Lessor’s Agent (if applicable)

Signature: __________________________
Name: [Full Name]
Date: [Date]

Buyer’s / Lessee’s Agent (if applicable)

Signature: __________________________
Name: [Full Name]
Date: [Date]