Form No. 9600-040
Disclosure of Information on Lead-Based Paint and/or Lead-Based Paint Hazards
Lead Warning Statement
Every purchaser of any interest in residential real property on which a residential dwelling
was built prior to 1978 is notified that such property may present exposure to lead from lead-
based paint that may place young children at risk of developing lead poisoning. Lead
poisoning in young children may produce permanent neurological damage, including
learning disabilities, reduced intelligence quotient, behavioral problems, and impaired
memory. Lead poisoning also poses a particular risk to pregnant women. The seller of any
interest in residential real property is required to provide the buyer with any information on
lead-based paint hazards from risk assessments or inspections in the seller’s possession and
notify the buyer of any known lead-based paint hazards. A risk assessment or inspection for
possible lead-based paint hazards is recommended prior to purchase.
Seller’s Disclosure
(a) Presence of lead-based paint and/or lead-based paint hazards (initial (i) or (ii)
below):
(i) ______ Known lead-based paint and/or lead-based paint hazards are present in the
housing. Describe what is known:
___________________________________________________________________________________________________________
(ii) ______ Seller has no knowledge of lead-based paint and/or lead-based paint
hazards in the housing.
(b) Records and reports available to the seller (initial (i) or (ii) below):
(i) _______ Seller has provided the purchaser with all available records and reports
pertaining to lead-based paint and/or lead-based paint hazards in the
housing. List documents below:
(ii) ______ Seller has no reports or records pertaining to lead-based paint
and/or lead-based paint hazards in the housing.
Purchaser’s Acknowledgment
(c) Purchaser has (initial (i) or (ii) below):
(i) ______ received copies of all records and reports pertaining to lead-based
paint and/ or lead-based paint hazards in the housing listed above.
(ii) ______ not received any records and reports regarding lead-based paint and/
or lead-based paint hazards in the housing.
(d) ________ Purchaser has received the pamphlet Protect Your Family from Lead in
Your Home (initial).
(e) Purchaser has (initial (i) or (ii) below):
(i) ______ received a 10-day opportunity (or mutually agreed upon period) to
conduct a risk assessment or inspection for the presence of lead-based paint and/or
lead- based paint hazards; or
_________________________________________________________________________________________________________
(ii) _______ waived the opportunity to conduct a risk assessment or inspection for
the presence of lead-based paint and/or lead-based paint hazards.
Agent’s Acknowledgment (initial or enter N/A if not applicable)
(f) _____________ Seller’s Agent has informed the seller of the seller’s obligations under 42 U.S.C.
4852d and is aware of his/her responsibility to ensure compliance.
(g) _________ Purchaser’s Agent has informed the seller of the seller’s obligations under 42
U.S.C. 4852d and is aware of his/her responsibility to ensure compliance.
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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.
Seller
Date
Purchaser
Date
Seller
Date
Purchaser
Date
Seller’s Agent
Date
Purchaser’s Agent
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Date
Paperwork Reduction Act
This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501
et seq. (OMB Control No. 2070-0151). Responses to this collection of information are mandatory (40
CFR 745). An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number. The public reporting
and recordkeeping burden for this collection of information is estimated to be 0.12 hours per response.
Send comments on the Agency’s need for this information, the accuracy of the provided burden
estimates and any suggested methods for minimizing respondent burden to the Regulatory Support
Division Director, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW,
Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the
completed form to this address.”
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Only required if the purchaser’s agent receives compensation from the seller.
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