# Sample Format

# Lead-Based Paint Disclosure Addendum 

## Property Case #: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Property Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**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
    (check (i) or (ii) below):

(i)\_\_\_\_ Seller has knowledge of lead-based paint and/or lead-based
paint hazards 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.

**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]{.underline}.

(e)\_\_\_\_ Purchaser has a 15-day contingency period from the date of
its signature below to exercise the option to conduct a lead-based paint
inspection or risk assessment at its own expense for the presence of
lead-based paint and/or lead-based paint hazards. The Purchaser may
withdraw from this purchase obligation by providing written notice to
the Seller on or before this date. The Purchaser will be entitled to a
refund of earnest money if the Purchaser obtained an independent
lead-based paint inspection or risk assessment performed by a Certified
Lead-Based Paint Inspector or Risk Assessor, as applicable, and the
Purchaser provides the Seller with a copy of the lead-based paint
inspection or risk assessment report.

**Agent's Acknowledgment** (initial)

(f)\_\_\_\_Selling Broker is aware of his/her responsibilities to ensure
compliance with 42 U.S.C. 4852d.

**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 Purchaser Date

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Selling Broker/ Agent Date Selling Broker/Agent Date

cc: HX-9139, Chron-9176, Donahoe-9180

HUFA:DONAHOE:jd/ct 8/25/03 J:\\Jerry\\Lead Disclosure -- Interim Form
8.19.03

AA-0376100

HUFA HUFA HUFA HUF HU H

Donahoe Washington Sampedro McCloskey Coonts Cassidy