Sample COF Pre-Renovation Form

Sample Pre-Renovation Form
This sample form may be used by contractors in documenting compliance with the Federal lead
disclosure and renovation regulations.

Occupant Confirmation
❑ I have received a copy of the lead hazard information pamphlet informing me of the potential
risk of the lead hazard exposure from renovation activity to be performed in my dwelling unit. I
received this pamphlet before the work began.
❑ I confirm that I own and live in this property, and that no child under the age of 6 resides or is
provided child care here.
Note: A child may reside in the primary residence of his or her custodial parents, legal guardians, foster
parents, or informal caretaker if the child lives and sleeps most of the time at the caretaker's residence.

❑ I confirm that no child under the age of 6 residing or being provided child care in this home
has been diagnosed with an elevated blood lead level by a qualified medical professional.
_____________________________________
Printed name of recipient

_____________________________
Date

_____________________________________
Signature of recipient

Self Certification Option (for tenant-occupied dwellings only)
If the lead hazard information pamphlet was delivered but a tenant signature was not obtainable,
you may check the appropriate box below.
❑ Refusal to sign – I certify that I have made a good faith effort to deliver the lead hazard
information pamphlet to the rental dwelling unit listed below at the date and time indicated and
that the occupant refused to sign the confirmation of receipt. I further certify that I have left a
copy of the pamphlet at the unit with the occupant.
❑ Unavailable for signature – I certify that I have made a good faith effort to deliver the lead
hazard information pamphlet to the rental dwelling unit listed below and that the occupant was
unavailable to sign the confirmation and time of receipt. I further certify that I have left a copy
of the pamphlet at the unit by sliding it under the door.
____________________________________
Printed name of person certifying
lead pamphlet delivery

_____________________________
Attempted delivery date

____________________________________
Signature of person certifying lead pamphlet delivery
____________________________________
____________________________________
____________________________________
Unit Address
Note Regarding Mailing Option--As an alternative to delivery in person, you may mail the lead
hazard information pamphlet to the owner and/or tenant. Pamphlet must be mailed at least seven
days before renovation. Document with a certificate of mailing from the post office.
—Occupant’s Copy—