Here's what I have used:
Every purchaser or Tenant of any residential real property on which a residential dwelling was built prior to 1978 is hereby 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. Prior to renting or leasing a residence built prior to 1978, Owner is required to provide Tenant with any known information on lead-based paint hazards from risk assessments or inspections in the Owner’s possession and notify Tenant of any known lead-based paint hazards. Tenant is entitled to, at their own cost and expense, cause a risk assessment or inspection for possible lead-based paint hazards. Tenant must also receive a copy of the pamphlet Protect Your Family from Lead in Your Home or an equivalent lead hazard information pamphlet approved by the federal Environmental Protection Agency.
Owner Disclosure: (Initial where applicable if the Premises was built prior to 1978) Owner has no knowledge of lead-based paint or lead-based paint hazards in the Premises. Owner has no reports or records pertaining to lead-based paint and/or lead-based paint hazards in the Premises. Owner Initials: ________ / ________
Tenant Acknowledgements: Tenant has knowledge that the online pamphlet Protect Your Family From Lead In Your Home, or its approved equivalent can be viewed at: (link to EPA website, not sure if links allowed?) and has had the option to request a printed copy of said pamphlet and has done so (or declined to do so). Tenant has received copies of all records and reports attached hereto. Tenant has waived the opportunity to conduct a risk assessment or inspection for the presence of lead-based paint and/or lead-based paint hazards. Tenant agrees to promptly inform Owner in writing of any deteriorated and/or peeling paint in the Premises.
Tenant Initials: _____ / _____ / _____ / _____ / _____ / _____