FORMS STORE

Complete Your Custom ORHA Rental Form

Please Fill In the Form

Save/Update Auto-Fill Entries

M5 : LEAD-BASED PAINT DISCLOSURE

Required entries are indicated by blue icons or *

Tenant(s)* (required)

Tenant(s)

et al (and all others)

Property Address* (required)

Unit #

City (Oregon ONLY)

OREGON Zip Code

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):

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

Explanation

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)

Document List

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

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

M5 : LEAD-BASED PAINT DISCLOSURE

Rev.11/16

Click "Preview Form" below to check your information.
If the form is correct, close the preview to return to this page, then click"Generate PDF". Your form will be created and added to your cart.
From your cart, you can return to the Forms Store to create more forms, delete forms from your cart or purchase the items in your cart.

Preview Form