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Lead Based Paint Disclosure -Form Fill

Section One
Q1

Presence of lead-based paint and/or lead-based paint hazards
Q2

Please Explain
Q3

Records and reports available to the seller
Q4

Please upload records or reports
Q5

Purchaser has
Q6

Agent has
Q7

Following Parties have
Q8

Date

Date
Q9

Seller Name

First Name
Q10

Seller Name

Last Name
Q11

Seller Signature
Q12

Purchaser Name

First Name
Q13

Purchaser Name

Last Name
Q14

Purchaser Signature
Q15

Agent Name

First Name
Q16

Agent Name

Last Name
Q17

Agent Signature