Lead-Based Paint Notification
This notice is intended to help conform to Federal lead paint notification requirements.
The undersigned hereby acknowledges and agrees to the following:
1. That the undersigned was informed that the premises they are renting at:
_____________________ may contain lead-based paint.
2. That the undersigned are aware that lead-based paint can poison and is hazardous
to one's health, particularly children under 6 years of age, and can
cause permanent damage if ingested.
3. That the undersigned was given a pamphlet issued by EPA, labeled: form
EPA747-K-94-001, May 1995, that explains lead-based paint hazards.
4. That the undersigned takes full responsibility for any injury caused by
lead-based paint to themselves, or anyone residing in , or visiting the premises, while in
the undersigned's control.
5. That the undersigned shall hold ____________________________________, landlords,
or their officers or agents harmless for any injury caused by lead based paint.
6. That the undersigned will inform the landlord if they suspect a lead-based
problem, especially with chipping, flaking or pealing paint.
Dated: ___________________
___________________________________________
[Occupant's Signature]
___________________________________________
[Occupant's Signature]
State of __________________ )
County of ________________ )
This day, before me, a Notary Public in said County, personally came
__________________________,
and ________________________________, and acknowledged the signing of this document to
be a voluntary act.
IN WITNESS WHEREOF I have hereunto set my hand and official seal.
My commission expires: __________________
________________________________
Notary Public