Fill and Sign the F Agent Has Informed the Seller of the Seller Obligations under 42 U

Lead -Based Paint Disclosure (Sales) _________________________________ _____ __ ______________ _____ Massachusetts _____________________ 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 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 haz ards. 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 (check (i) or (ii) below): (i) _____ Known lead -based pain t and/or lead -based paint hazards are present in the housing (explain). _________________________________________________________________________________________ __ ________________________________________ ___________________________________________________ (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 (check (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 (initial) (c) ________ Purchaser has received co pies of all information listed above. (d) ________ Purchaser has received the pamphlet Protect Your Family from Lead in Your Home. (e) Purchaser has (check (i) or (ii) below): (i) _____ Received a 10 -day opportunity (or mutually agreed upon period) to con duct 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) (f) ________ Agent has informed the seller of the seller' obligations under 42 U.S.C. 4852(d) and is aware of his/her respons ibility to ensure compliance. Seller Initials: ________ _________ Buyer Initials: _______ __ _________ Agent Initials: ________ _____ ____ Certification of Accuracy for Lead -Based Paint Disclosure The following parties have reviewed the information above and certify, to the best of their knowledge, that the information t hey have provided is true and accurate. Penalties for failure to comply with Federal Lead -Based Paint Disclosure Laws include trebl e (3 times) damages, attorney fees, costs, and a penalty up to $10,000 for each violation. _________________________ ______ _____________ _________________________ _______ ____________ Seller Date Buyer Date _________________________ ______ _____________ _________________________ _______ ____________ Seller Date Buyer Date _________________________ ______ _____________ _________________________ _______ ____________ Seller’s Agent (if any) Date Buyer’s Agent (if any) Date *** THIS IS AN INSTRUCTION PAGE: IT IS NOT PART OF THE FORM *** The Free EPA Pamphlet: For houses built prior to 1978, the Seller must give the Purchaser a copy of the EPA -approved information pamphlet on ident ifying and controlling lead -based paint hazards entitled, "Protect Your Family From 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 browse r): http://www.epa.gov/sites/production/files/2013 -09/documents/lead_in_your_home_brochure_land_color_508.pdf See also: http://www.epa.gov/lead/pubs/leadpdfe.pdf The form is in .pdf format and you will need the free Adobe Acrobat Reader to view the form. In the unlikely circumstance that the Adobe Acrobat Reader is not installed on y our computer, you can download it free from http://www.adobe.com/ products/acrobat/readstep2.html . The download is quick and easy.