Fill and Sign the Fillable Online Report Form the City Clerk Regarding a

Lead-Based Paint Disclosure (Sales) ________________________________________ ___________________ Vermont _____________________ 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 dwel ling 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 permane nt neurological damage, including learning disabilities, reduced intelligence quotient , behavioral problems, and impaired memory. Lead poisoning also poses a particular risk to pregnant women. The Selle r of any interest in residential real property is required to provide the buyer with any information on lead-base d paint hazards from risk assessments or inspections in the Seller's possession and notify the buyer of any known lead-based pa int hazards. A risk assessment or inspection for possible lead-based paint hazards is recommended pri or 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 paint 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 le ad- 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 copies 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 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) (f) ________ Agent has informed the seller of the seller' obligations under 42 U.S.C. 4852(d) and is aware of his/her responsibility 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 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. _______________________________ _____________ ________________________________ ____________ 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 identifying 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 browser): 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 your computer, you can download it free from http://www.adobe.com/products/acrobat/readstep2.html . The download is quick and easy.