Disclosure of Information and Acknowledgement About
Lead-Based Paint and Lead-Based Paint Hazards

I. Lead Paint Warning

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 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.

II. Property Address:_________________________________________________

III. Seller's Disclosure (Initial) (To be competed and signed at time of listing)

_____(a) Present of lead-based paint and/or lead-based paint hazards (check one below):

Known lead-based paint and/or lead-based paint hazards are present in the housing (explain).

________________________________________________________________________________

________________________________________________________________________________

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 one below):

Seller has no reports or records pertaining to lead-based paint and/or lead-based hazards in the housing.

Seller has the following reports or records pertaining to lead-based paint and/or lead-based paint hazards in the housing all of which seller has provided to its listing agent, and has directed its listing agent to provide purchaser or purchaser's agent with these records prior to seller accepting any offer to purchase (list documents below):

________________________________________________________________________________

________________________________________________________________________________
_____(c) If there is any change in the above information prior to seller accepting an offer from the purchaser to purchase, seller will disclose all changes to the purchaser prior to accepting the offer.

IV. Seller's Certification of Accuracy

Seller(s) have reviewed the Seller's Disclosure in Section III and certify, to the best of his/her/their knowledge, that the information they have provided is true and accurate.
Seller________________________________Date___/___/___Seller________________________Date___/___/___

V. Listing Agent's Certification of Accuracy

Listing Agent certifies that he/she has informed the seller of the seller's obligations under 42 U.S.C. 4852d and is aware of his/her responsibility to ensure compliance.
Listing Agent_______________________________________Date___/___/___

VI. Purchaser's Acknowledgement (initial) (The Seller's Disclosure in Section III and Certification in Section IV and the Listing Agent's Certification in Section V to be completed and signed prior to purchaser signing this Addendum A.)

_____(a) Purchaser has received copies of all information listed in Section III above.
_____(b) Purchaser has received the pamphlet Protect Your Family from Lead in Your Home.
_____(c) Purchaser has (check on below):
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
Waived the opportunity to conduct a risk assessment or inspection for the presence of lead-based paint and/or lead-based paint hazards.

VII. Purchaser's Certification of Accuracy

Purchaser(s) have reviewed the Purchaser's Acknowledgement in Section VI and certify, to the best of his/her/their knowledge, the information they have provided is true and accurate.
Purchaser_____________________________Date___/___/___Purchaser_____________________Date___/___/___

VIII. Selling/Buyer's Agent's Certification of Accuracy

Selling/Buyer's Agent certifies that the purchaser received the information in section VI (a) and (b).
Selling/Buyer's Agent_______________________________________Date___/___/___