Sample Disclosure Format for Target Housing Sales
Disclosure of Information on Lead-Based Paint and/or Lead-Based Paint Hazards

Lead Warning Statement

Every purchaser 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 lead-based paint that may place
young children at risk of developing lead poisoning. Lead poisoning in young children may produce
permanent neurological damage, 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 seller's 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's Disclosure (initial)

__________(a) Presence of lead-based paint and/or lead-based paint hazards (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 for the presence of lead-based paint and/or lead-based paint hazards; or
Waived the opportunity to conduct a risk assessment or inspection for the presence of 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 provided by the signatory is true and accurate.

___________________ __________ _____________________ ________

Seller                                    Date               Seller                                       Date

___________________ __________ _____________________ ________
Purchaser                                 Date         Purchaser                             Date

___________________ __________ _____________________ ________
Agent                                     Date          Agent                                 Date