ILLINOIS ASSOCIATION OF REALTORS
DISCLOSURE OF INFORMATION AND ACKNOWLEDGMENT
LEAD-BASED PAINT AND/0R 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
damages, 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 DISCLOSURE (Initial)
___(a) Presence of lead-based paint and/or lead-based paint hazard
(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 provided the purchaser with all available records and
reports pertaining to lead-based paint and/or lead-based paint
hazards in the housing (list documents below):
____________________________________________________________________
____________________________________________________________________
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 one below):
Received a 10-day opportunity (or mutually agreed upon period) to
conduct a risk assessment or inspection of the presence of
lead-based paint or lead-based paint hazards; or
Waived the opportunity to conduct a risk assessment or inspection
for the presence or 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 _________
Seller__________________________ Date _________
Agent _________________________ Date _________
Purchaser______________________ Date _________
Purchaser______________________ Date _________
Agent_________________________ Date _________
Property Address:_______________________
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