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FORM #51 - Lead-Based Paint Disclosure

  • Tenant(s):
  • Tenant(s):
  • Address: Unit:
  • City: , OREGON Zip:

Lead-Based Paint 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 lead-based paint and/or lead-based paint hazards in the dwelling. Lessees must also receive a federally approved pamphlet on lead poisoning prevention.

Owner/Agent Disclosure

  • ____ Presence of lead-based paint or lead-based paint hazards (check one below):
    • ____ Known lead-based paint and/or lead-based hazards are present in the housing (explain).
    • ____ Owner/Agent has no knowledge of lead-based paint and/or lead based paint hazards in the housing.
  • ____ Records and reports available to the Tenant (check one below):
    • ____ Owner/Agent has provided the Tenant with all available records and reports pertaining to lead-based paint and/or lead based paint hazards in the housing (list documents below)
    • ____ Owner/Agent has no reports or records pertaining to lead-based paint and/or lead-based paint hazards in the housing.

Tenant(s) Acknowledgement

  • ____ Tenant has received copies of all information listed above.
  • ____ Tenant has received the pamphlet Protect Your Family from Lead in Your Home.

Owner/Agent Acknowledgement

  • ____ Owner/Agent has informed the Owner of the Landlord’s obligations under 42 USC 4852(d) 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 is true and accurate:


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