9600-040 Seller's Disclosure of Information on Lead-Based Paint

OMB Control No. 2070-0151
Expiration Date: 7/31/2023

Disclosure of Information on Lead-Based Paint and/or Lead-Based Paint Hazards

Lead Warning Statement
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 inspections
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.
Seller’s Disclosure
(a) Presence of lead-based paint and/or lead-based paint hazards (check (i) or (ii) below):
(i) ______ Known lead-based paint and/or lead-based paint hazards are present in the housing
(explain).
_______________________________________________________________________________________
(ii) _____ 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 (i) or (ii) below):
(i) ______ Seller has provided the purchaser with all available records and reports pertaining to leadbased paint and/or lead-based paint hazards in the housing (list documents below).
_______________________________________________________________________________________
(ii) _____ Seller has no reports or records pertaining to lead-based paint and/or lead-based paint
hazards in the housing.
Purchaser’s Acknowledgment (initial)
(c) ________ Purchaser has received copies of all information listed above.
(d) ________ Purchaser has received the pamphlet Protect Your Family from Lead in Your Home.
(e) Purchaser has (check (i) or (ii) below):
(i) _____ 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
(ii) _____ waived the opportunity to conduct a risk assessment or inspection for the presence of
lead-based paint and/or lead-based paint hazards.
Agent’s Acknowledgment (initial)
(f) ________ Agent 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.
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.

__________________________________________________
Seller
Date
__________________________________________________
Purchaser
Date
__________________________________________________
Agent
Date

EPA Form 9600-040

__________________________________________________
Seller
Date
__________________________________________________
Purchaser
Date
__________________________________________________
Agent
Date

PRA Burden Statement for Collection Instruments:
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.”