"Lead Disclosure Form" - Washington, D.C.

Lead Disclosure Form is a legal document that was released by the Washington DC Department of Energy & Environment - a government authority operating within Washington, D.C..

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LEAD DISCLOSURE FORM
Federal 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.
ADDRESS OF PROPERTY, INCLUDING UNIT NUMBER IF ANY:
____________________________________________________________________________________
The District of Columbia “Lead-Hazard Prevention and Elimination Act of 2008,” as amended (the
“Act”), D.C. Official Code § 8-231.01 et seq., requires an owner of a residential property constructed
before 1978 to disclose the information contained in this Lead Disclosure Form to prospective tenants or
prospective property purchasers, before any change in occupancy or contract for possession is executed.
Owners are required to disclose specific information which they know or reasonably should know about
the property related to the presence of lead-based paint and/or lead-based paint hazards, and any pending
actions ordered under the Act. To meet the requirements of this law, you must complete this Lead
Disclosure Form.
I am the owner or authorized owner’s agent of (Insert Full Address of Property)
_____________________________________________________________________________________
and affirm that the following answers state what I reasonably know about my property.
CHECK ONE BOX UNDER A, B, AND C, BELOW.
A. Check one of the following 3 statements that accurately describes what you know about the
presence of lead-based paint on your property:
□ Lead-based paint is known or reasonably known to be present on the interior or on the exterior of the
property (including common areas, if applicable), at the following locations (specify components, rooms,
and any other relevant details, and provide access to any available record or report about the presence
of lead-based paint at this property):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
□ To my knowledge, lead-based paint is not known or reasonably known to be present on the interior or
on the exterior of the property, including common areas. I will provide access to any record or report I
have about the absence of lead-based paint at this property.
□ While lead-based paint is not known by me to be present in the dwelling unit, it is presumed to be there,
because the dwelling unit was constructed prior to 1978.
B. Check one of the following 2 statements that accurately describes what you know or reasonably
should know about the condition of your property:
NOTE: The following definitions must be followed to comply with District law.
LEAD DISCLOSURE FORM
Federal 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.
ADDRESS OF PROPERTY, INCLUDING UNIT NUMBER IF ANY:
____________________________________________________________________________________
The District of Columbia “Lead-Hazard Prevention and Elimination Act of 2008,” as amended (the
“Act”), D.C. Official Code § 8-231.01 et seq., requires an owner of a residential property constructed
before 1978 to disclose the information contained in this Lead Disclosure Form to prospective tenants or
prospective property purchasers, before any change in occupancy or contract for possession is executed.
Owners are required to disclose specific information which they know or reasonably should know about
the property related to the presence of lead-based paint and/or lead-based paint hazards, and any pending
actions ordered under the Act. To meet the requirements of this law, you must complete this Lead
Disclosure Form.
I am the owner or authorized owner’s agent of (Insert Full Address of Property)
_____________________________________________________________________________________
and affirm that the following answers state what I reasonably know about my property.
CHECK ONE BOX UNDER A, B, AND C, BELOW.
A. Check one of the following 3 statements that accurately describes what you know about the
presence of lead-based paint on your property:
□ Lead-based paint is known or reasonably known to be present on the interior or on the exterior of the
property (including common areas, if applicable), at the following locations (specify components, rooms,
and any other relevant details, and provide access to any available record or report about the presence
of lead-based paint at this property):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
□ To my knowledge, lead-based paint is not known or reasonably known to be present on the interior or
on the exterior of the property, including common areas. I will provide access to any record or report I
have about the absence of lead-based paint at this property.
□ While lead-based paint is not known by me to be present in the dwelling unit, it is presumed to be there,
because the dwelling unit was constructed prior to 1978.
B. Check one of the following 2 statements that accurately describes what you know or reasonably
should know about the condition of your property:
NOTE: The following definitions must be followed to comply with District law.
DISTRICT OF COLUMBIA DEFINITION OF LEAD-BASED PAINT HAZARD: “Lead-based
paint hazard” means any condition that causes exposure to lead from lead-contaminated dust, lead-
contaminated soil, deteriorated lead-based paint or presumed lead-based paint, or lead-based paint or
presumed lead-based paint that is disturbed without containment. See D.C. Official Code § 8-231.01(22).
DEFINITION OF PRESUMED LEAD-BASED PAINT: “Presumed lead-based paint” means paint or
other surface coating affixed to a component in or on a dwelling unit or child-occupied facility,
constructed prior to 1978. See D.C. Official Code § 8-231.01(32).
□ I have reason to believe a lead-based paint hazard is present on the interior or on the exterior of the
property (including common areas, if applicable), at the following locations (specify components, rooms,
and any other relevant details, and provide access to any available record or report about the presence
of lead-based paint hazards at this property):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
□ To my knowledge, lead-based paint hazards are not present nor likely to be present on the interior or on
the exterior of the property, including common areas, if applicable. I will provide access to any record or
report I have about the absence of lead-based paint hazards at this property.
C. Check one of the following 2 statements that accurately describes whether any government
action is currently pending, with respect to your property or unit:
□ There are currently no pending actions ordered by a District Government agency with respect to the
property listed above.
□ There are currently pending actions that have been ordered by a District Government agency with
respect to this property, as follows:
____________________________________________________________________________________
____________________________________________________________________________________
By my signature below, I agree that this Lead Disclosure Form states information about my
property or unit listed above, which is reasonably known to me, and that I have answered the
questions in this form truthfully. I also agree to comply with the Act’s requirement that I provide
this information to my prospective tenants, as well as to any prospective purchasers, before they are
under any contract to purchase or lease a dwelling unit. I understand that falsification of any
information provided or required in this document may subject me to civil or criminal penalties.
D.C. Official Code § 8-231.15(b) and § 8-231.16(b).
_____________________________________ __
________________________
NAME OF OWNER/OWNER’S AUTHORIZED AGENT
DATE
GOVERNMENT OF THE
DISTRICT OF COLUMBIA
ACKNOWLEDGEMENT FORM
Disclosure of Information on Lead-Based Paint and/or Lead-Based Paint Hazards
and/or Pending Government Actions
ADDRESS OF PROPERTY, INCLUDING UNIT # IF ANY:
______________________________________________________________________________
Lessee’s Acknowledgement
□ I confirm that I have received a completed Lead Disclosure Form for the property address specified
above, and that I received it on (insert date):________________________
□ I confirm that I have received the pamphlet, Protect Your Family From Lead in Your Home, and that I
received it on (insert date):_________________________
__________________________
_____________________________
Lessee’s Signature
Date
Prospective Purchaser’s Acknowledgement
□ I confirm that I have received a completed Lead Disclosure Form for the property address specified
above, and that I received it on (insert date):________________________
□ I confirm that I have received the pamphlet, Protect Your Family From Lead in Your Home, and that I
received it on (insert date):_________________________
_______________________________________ _
___________________________
Prospective Purchaser’s Signature
Date
Agent’s Acknowledgement
I have informed the property owner of the property owner’s obligations under 42 U.S.C. 4852d, and I am
aware of my responsibility to ensure compliance.
_______________________________________ _______________________________
Agent’s Signature
Date
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