California Lead Based Paint Disclosure Form - Free Download
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California Lead Based Paint Disclosure Form
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Disclosure of Information on Lead-Based Paint and/or Lead-Based Paint Hazards
Lead 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 known lead-based
paint and/or lead-based paint hazards in the dwelling. Lessees must also receive a federally approved
pamphlet on lead poisoning prevention.
Lessor’s Disclosure
(a) Presence of lead-based paint and/or lead-based paint hazards (check (i) or (ii) below):
(i) ______ Known lead-based paint and/or lead-based paint hazards are present in the
housing (explain).
(ii) _____ Lessor has no knowledge of lead-based paint and/or lead-based paint hazards in the
housing.
(b) Records and reports available to the lessor (check (i) or (ii) below):
(i) ______ Lessor has provided the lessee with all available records and reports pertaining
to lead-based paint and/or lead-based paint hazards in the housing (list documents below).
(ii) _____ Lessor has no reports or records pertaining to lead-based paint and/or lead-based
paint hazards in the housing.
Lessee’s Acknowledgment (initial)
(c) ________ Lessee has received copies of all information listed above.
(d) ________ Lessee has received the pamphlet Protect Your Family from Lead in Your Home.
Agent’s Acknowledgment (initial)
(e) ________ Agent has informed the lessor of the lessor’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.
Lessor Date Lessor Date
Lessee Date Lessee Date
Agent Date Agent Date
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