C.A.R. Form FLD, Lead-Based Paint and Lead-Based Paint Hazards Disclosure, Acknowledgment and Addendum (Revised 11/10) Instructions

Enter the full printed name of the additional buyer or tenant to be included in this acknowledgment.

Enter the full printed name of the additional buyer or tenant to be included in this acknowledgment.

Enter the full legal name or names of the Buyer(s) or Tenant(s) being identified in this transaction.

Enter the full legal name or names of the Seller(s) or Landlord(s) being identified in this transaction.

Enter the buyer's or tenant's initials for the first indicated acknowledgment or disclosure item (use the same initials that identify you on the form).

Enter the buyer's or tenant's initials for the second indicated acknowledgment or disclosure item (use the same initials that identify you on the form).

Check this box when the buyer elects to waive the right to conduct a risk assessment or inspection for the presence of lead-based paint and/or lead-based paint hazards for this sales transaction.

Check this box when the cooperating agent has informed the Seller or Landlord (through the Listing Agent if the property is listed) of the Seller's or Landlord's obligations under §42 U.S.C. 4852d and is aware of the agent's responsibility to ensure compliance.

Enter the full name of the cooperating agent or broker who obtained the offer.

Enter the date when the cooperating agent signed or acknowledged this section.

Provide the printed name or signature text of the associate licensee or broker acknowledging the information above.

Enter the date when the first buyer or tenant signed or certified the acknowledgement.

Enter the printed name or signature text of the first buyer or tenant confirming they have reviewed and certify the information above.

Enter the name of the broker, agent, or preparer associated with this form as it appears in the footer.

Enter the broker or company's contact details or reference information shown in the footer (for example: address, phone, fax, license number, or other preparer reference).

Enter the page number or small form reference code printed in the footer area of the form.

Check this box when the listing agent has informed the seller or landlord of their obligations under §42 U.S.C. 4852d and acknowledges the agent’s responsibility to ensure compliance.

Enter the full printed name of the listing agent or broker representing the seller or landlord.

Enter the date on which the associate licensee or broker signed this acknowledgment.

Provide the signature of the associate licensee or broker to certify that they have reviewed the information above.

Enter the name of the broker or brokerage firm responsible for the listing (printed).

Enter the city, state and ZIP code for the property (for example 'Anytown, CA 90210').

Enter the street number and street name of the property being referred to (the full mailing/street address such as '123 Main St').

Check this box when the property is commonly known by the name entered on the adjacent 'property known as' line.

Enter the date when this form is completed.

Enter the full property street address for the listing, including unit or suite number if applicable, city, state, and ZIP code.

Check this box when you have entered or confirmed the correct property address for the transaction.

Enter the full name of the person who reviewed the form or document.

Enter the date on which the reviewer reviewed or signed this form.

Enter the full name of the person who reviewed the form.

Enter the date when the reviewer completed or signed the review.

Enter the name of the reviewer’s company, brokerage, office, or department associated with the review.

Enter the date on which the second buyer or tenant signed or acknowledged the document.

Enter the full printed name or signature of the second buyer or tenant to acknowledge they have reviewed and certify the information above.

Enter the full printed name of the first seller or landlord who is certifying and signing this form.

Enter any additional name information or initials for a seller or landlord (co‑signer, middle initial, or suffix) as needed.

Enter the date when the second seller or landlord signed this certification.

Enter the date when the third seller or landlord signed this certification.

Enter the date when the first seller or landlord signed this certification.

Enter the full printed name of the second seller or landlord who is certifying and signing this form.

Enter the full printed name of the third seller or landlord who is certifying and signing this form.

Provide a detailed description of all known lead-based paint and lead-based paint hazards for the property, including locations, dates, nature of hazard, and any known reports, inspections, remediation or abatement actions.

Enter a short description of any other known lead-based paint or lead-based paint hazards not covered elsewhere (e.g., brief note of exception, reference, or short qualifier).

Enter the full title and any identifying details (such as date, author, or attachment reference) of the first report or record that has been provided to the Buyer/Tenant regarding lead-based paint or lead-based paint hazards.

Enter the full title and any identifying details (such as date, author, or attachment reference) of the second report or record that has been provided to the Buyer/Tenant regarding lead-based paint or lead-based paint hazards.

Enter a brief title or short description of the report or record previously provided to the Buyer/Tenant (for example, report name, date, or source).

Enter the date of the underlying agreement referenced above.

Enter the title, reference, or identifying name of the underlying agreement (for example, Purchase Agreement or Residential Lease) that these terms are incorporated into.

If the agreement is not one of the listed types, enter the other agreement type or brief description here. Fill only if 'Other (Specify agreement and date)' is 'Yes'.

Check this box when the lead-based paint disclosure is being incorporated into a residential lease or month-to-month rental agreement.

Check this box when the disclosure is being incorporated into a California Residential Purchase Agreement.

Check this box when the disclosure applies to another type of agreement, and specify the agreement type and its date on the provided line.