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Lead Paint Disclosure Form

In 1992 Congress passed the Residential Lead-Based Paint Hazard Reduction Act and is also referred to as Title X. Title X was designed to protect families from exposure to lead from paint, dust and soil. Title X directs HUD and the EPA to require that there is full disclosure of all known information regarding lead-based paint and any lead-based paint hazards before the sale or lease of housing that was built before 1978. A sample of this required disclosure is found below.

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Lead Paint Template

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Lead Paint Disclosure Agreement

Effective Date: ____/____/______

Tenant [Legal Name] (AKA, "The Lessee")

Located at [Address]

[City], [State] [Zip Code]


Landlord [Legal Name](AKA, "The Lessor")

Located at [Address]

[City], [State] [Zip Code]

The above mentioned parties do hereby agree as follows:

Statement of Warning for Lead:

Housing that was built before 1978 may contain paint that is lead-based. If not managed properly lead from paint, paint chips, and dust can pose health hazards. Lead exposure is especially harmful to young children and pregnant women. Lessors must disclose the presence of paint that is lead-based and / or lead-based paint hazards that are present in the dwelling before renting. A federally approved pamphlet on lead poisoning prevention must also be given to all Lessees.

Lessor's Disclosure:

Presence of lead-based paint and / or lead-based paint hazards:

[__] There are known lead-based paint and / or lead based paint hazards in the housing unit.

Details: _____________________________________________________


[__] The Lessor has no knowledge of any lead-based paint and / or any lead-based paint hazards in the housing unit.

Records and reports that were made available to the Lessor:

[__] The Lessor has provided the Lessee with all available records and reports that pertain to lead based paint and / or lead-based paint hazards in the housing unit.

Documents provided: __________________________________________



[__] The Lessor has no knowledge of any lead-based paint and / or any lead-based paint hazards in the housing unit.

Lessee's Acknowledgment:

______ (Initial) Lessee has received copies of all information listed above.

______ (Initial) Lessee has received the pamphlet Protect Your Family from Lead in Your Home.

Agent's Acknowledgement:

______ (Initial) 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.

The following parties signed below have reviewed the above information and hereby certify to the best of their knowledge that the information that they have provided is accurate and true.

Signature of the Lessee

Signature of the Lessor

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