Fill and Sign the Connecticut Rental Form

Lead -Based Paint Disclosure (Rental) _________________________________ _____ __ ______________ _____ Connecticut _____________________ Street Address City State Zip Code WARNING! LEAD FROM PAINT, DUST, AND SOIL CAN BE DANGEROUS IF NOT MANAGED PROPERLY 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 expos ure 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 pa mphlet 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 th e housing (list documents below). ___________________________________________________________________________________________ ___________________________________________________________________________________________ (ii) _____ Lessor has no reports or r ecords 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 Fa mily from Lead in Your Home. Agent's Acknowledgment (e) ________ Agent has informed the lessor of the lessor's obligations under 42 U.S.C. 4852(d) and is aware of his/her responsibility to ensure compliance. Certification of Accuracy The following parti es have reviewed the information above and certify, to the best of their knowledge, that the information they have provided is true and accurate. Penalties for failure to comply with Federal Lead -Based Paint Disclosure Laws include treble (3 times) damages , attorney fees, costs, and a penalty up to $10,000 for each violation. _________________________ ______ _____________ _________________________ _______ ____________ Lessor Date Lessee Date _________________________ ______ _____________ __________________ _______ _______ ____________ Lessor Date Lessee Date _________________________ ______ _____________ _________________________ _______ ____________ Lessor’s Agent (if any) Date Lesses ’s Agent (if any) Date * NOTE: THIS IS AN INSTRUCTION PAGE – IT IS NOT PART OF THE FORM * The Free EPA Pamphlet: If the dwelling unit was built prior to 1978, the landlord must give the tenants the EPA -approved information pamphlet on identifying and controlling lead -based paint hazards entitled "Protect Your Family Fr om Lead In Your Home." You may obtain and print this pamphlet free by clicking the following download link (or copying the link into the address window of your internet browser) . The three links will all lead you to the document : http://www.epa.gov/lead/pubs/leadpdfe.pdf https://www.epa.gov/lead/protect -your -family -lead -your -home https://www.epa.gov/sites/production/files/2014 - 02/documents/lead_in_your_home_brochure_land_b_w_508_easy_print_0.pdf The form is in .pdf format and you will ne ed the free Adobe Acrobat Reader to view the form. In the unlikely circumstance that the Adobe Acrobat Reader is not installed on your computer, you can download it free from http://www. adobe.com/products/acrobat/readstep2.html . The download is quick and easy.