2507.05 Sample Prerenovation

Sample Pre-Renovation Form

Form Approved OMB No. 2070-0195 Expires 2/29/24

This sample form may be used by firms to document compliance with the requirements of the Federal LeadBased Paint Renovation, Repair, and Painting Program.
Occupant Confirmation
Pamphlet Receipt
___ 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.
Printed Name of Owner-occupant

Signature of Owner-occupant

Signature Date

Renovator’s Self Certification Option (for tenant-occupied dwellings only)
Instructions to Renovator: If the lead hazard information pamphlet was delivered but a tenant signature was not
obtainable, you may check the appropriate box below.
___ Declined – 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 declined 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 of receipt. I further certify that I have left a copy of the pamphlet at the unit by
sliding it under the door or by (fill in how pamphlet was left).

Printed Name of Person Certifying 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 7 days
before renovation. Mailing must be documented by a certificate of mailing from the post office.

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This collection of information is approved by OMB under the Paperwork
Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2070-0195). 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 range from 0.2 to 0.5 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
including through the use of automated collection techniques to the Director,
Regulatory Support Division, 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.