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Form #51 : LEAD-BASED PAINT DISCLOSURE

 

Required entries are indicated by blue icons or *

et al (and all others)

 

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.

Please Note: Some fields on this form must be initialed by the designated individual(s) after printing.

 

OWNER/AGENT DISCLOSURE (initial)

 

____ Presence of lead-based paint or lead-based paint hazards (check one below):

 

____ Records and reports available to the Tenant (check one below):

 
 

TENNANT(S) ACKNOWLEDGEMENT (initial)

 

____ Tenant has received copies of all information listed above.

____ Tenant has received the pamphlet Protect Your Family from Lead in Your Home.

 

AGENT ACKNOWLEDGEMENT (initial)

 

____ 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:

 

Please Note: Signature fields must be filled in and signed by all parties after printing.

 
Tenant Date   Tenant Date
 
Tenant Date   Tenant Date
 
Tenant Date   Tenant Date
 
Owner/Agent Date   Owner/Agent Date

FORM 51 MANDATORY REQUIREMENT

Download the EPA Publication Protect Your Family From Lead in Your Home using the link below.
(You must provide this to the Tenant when using this form)
EPA Pamphlet Download... 
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