To: Tenant From: Landlord Date: ANNUAL NOTICE PROTECT YOUR CHILD FROM LEAD POISONING AND WINDOW FALLS New York City law requires that tenants living in buildings with 3 or more apartments complete this form and return it to their landlord before February 15, each year. If you do not return this form, your landlord is required to visit your apartment to determine if children live in your apartment. Peeling Lead Paint Window Guards By law, your landlord is required to inspect your apartment for peeling paint and other lead paint hazards at least once a year if a child under 6 years of age (5 years or younger) lives with you. By law, your landlord is required to install window guards in all your windows if a child under 11 years of age (10 years or younger) lives with you, OR if you request them (even if no children live with you). You must notify your landlord in writing if a child under 6 comes to live with you during the year. It is against the law for you to interfere with installation, or remove window guards where they are required. Air conditioners in windows must be permanently installed. If a child under 6 lives with you, your landlord must inspect your apartment and provide you with the results of these paint inspections. Your landlord must use safe work practices to repair all peeling paint and other lead paint hazards. Always report peeling paint to your landlord. Call 311 if your landlord does not respond. These requirements apply to buildings with 3 or more apartments built before 1960. They also apply to buildings built between 1960 and 1978 if the landlord knows that lead paint is present. Window guards must be installed so there is no space greater than 4½ inches above or below the guard, on the side of the guard, or between the bars. ONLY windows that open to fire escapes, and one window in each first floor apartment when there is a fire escape on the outside of the building, are legally exempt from this requirement. These requirements apply to all buildings with 3 or more apartments, regardless of when they were built. Fill out and detach the bottom part of this form and return it to your landlord. -------------------------------------------------------------------------------------------- Please check all boxes that apply: A child under 6 years of age (5 years or younger) lives in my apartment. A child under 11 years of age (10 years or younger) lives in my apartment and: Window guards are installed in all windows as required. Window guards need repair. Window guards are NOT installed in all windows as required. No child under 11 years of age (10 years or younger) live in my apartment: I want window guards installed anyway. I have window guards, but they need repair. Last Name First Name Street Address Apt.# Signature Middle Initial City Date State Zip Code Telephone Number Deadline for return: February 15, 2012 Return form to: Name and address of landlord or managing agent. Call 311 for more information on preventing lead poisoning and window falls. DOHMH-approved: October 18, 2011 American LegalNet, Inc. www.FormsWorkflow.com