9600-041 Lessor's Disclosure of Information on Lead-Based Paint

OMB Control No. 2070-0151
Expiration Date: 11/30/2022
Disclosure of Information on Lead-Based Paint and/or Lead-Based Paint Hazards

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.
Lessor’s Disclosure
(a) Presence of lead-based paint and/or lead-based paint hazards (initial (i) or (ii)
below):
(i)
Known lead-based paint and/or lead-based paint hazards are present in
the housing. Describe what is known:
(ii)
Lessor has no knowledge of lead-based paint and/or lead-based
paint hazards in the housing.
(b) Records and reports available to the lessor (initial (i) or (ii) below):
(i)
Lessor has provided the lessee with all available records and reports
pertaining to lead-based paint and/or lead-based paint hazards in the housing. List
documents below:
(ii)
Lessor has no reports or records pertaining to lead-based paint
and/or lead-based paint hazards in the housing.

Lessee’s Acknowledgment
(c) Lessee has (initial (i) or (ii) below):
(i)
received copies of all records and reports pertaining to lead-based
paint and/ or lead-based paint hazards in the housing listed above.
(ii)
not received any records and reports regarding lead-based paint
and/or lead-based paint hazards in the housing.
(d)
Lessee has received the pamphlet Protect Your Family from Lead in Your Home
(initial).

Agent’s Acknowledgment (initial or enter N/A if not applicable)
(e)
Lessor’s Agent has informed the lessor of the lessor’s obligations under 42 U.S.C.
4852d and is aware of his/her responsibility to ensure compliance.
(f)
Lessee’s Agent has informed the lessor of the lessor’s obligations under 42 U.S.C.
4852d and is aware of his/her responsibility to ensure compliance.1

EPA Form No. 9600-041

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.
Lessor

Date

Lessee

Date

Lessor’s Agent

Date

Lessee’s Agent1

Date

Lessor

Date

Lessee

Date

Paperwork Reduction Act
This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501
et seq. (OMB Control No. 2070-0151). Responses to this collection of information are mandatory (40
CFR 745). An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number. The public reporting
and recordkeeping burden for this collection of information is estimated to be 0.12 hours per
response. Send comments on the Agency’s need for this information, the accuracy of the provided
burden estimates and any suggested methods for minimizing respondent burden to the Regulatory
Support Division Director, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave.,
NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the
completed form to this address.”

1

Only required if the lessee’s agent receives compensation from the lessor.