Fill and Sign the Lead Based Paint Disclosure Form 497307075

Lead-Based Paint Disclosure (Rental) ________________________________________ ___________________ Indiana _____________________ 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 exposure 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 pamphlet 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 the housing (list documents below). ___________________________________________________________________________________________ ___________________________________________________________________________________________ (ii) _____ Lessor has no reports or records 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 Family 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. Certifcation 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. 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 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). 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 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.