DISCLOSURE OF INFORMATION AND ACKNOWLEDGMENT
LEAD-BASED PAINT AND/0R LEAD-BASED PAINT HAZARDS


LEAD WARNING STATEMENT
Every purchase 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 ead-based paint that may place young children at risk of developing lead poisoning. Lead poisoning in young children may produce permanent neurological damages, 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 sellerís 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.

SELLER DISCLOSURE (Initial)

___(a) Presence of lead-based paint and/or lead-based paint hazard (check one below):

Known lead-based paint and/or lead-based paint hazards are present in the housing (explain):
____________________________________________________________________
____________________________________________________________________

  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 one below):

  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 below):
____________________________________________________________________
____________________________________________________________________

  Seller has no reports or records pertaining to lead-based paint and/or lead-based paint hazards in the housing

PURCHASER'S ACKNOWLEDGMENT (Initial):

___(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 one below):

  Received a 10-day opportunity (or mutually agreed upon period) to conduct a risk assessment or inspection of the presence of lead-based paint or lead-based paint hazards; or

Waived the opportunity to conduct a risk assessment or inspection for the presence or lead-based paint and/or lead-based paint hazards.

AGENT'S ACKNOWLEDGMENT (Initial):

___(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 .

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

Seller__________________________ Date _________
Seller__________________________ Date _________
Agent _________________________ Date _________

Purchaser______________________ Date _________
Purchaser______________________ Date _________
Agent_________________________ Date _________

Property Address:_______________________
                       
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