LEASE/COMMENCEMENT OF OCCUPANCY NOTICE FOR PREVENTION OF LEADBASED PAINT HAZARDS--INQUIRY REGARDING CHILD You are required by law to inform the owner if a child under six years of age resides or will reside in the dwelling unit (apartment) for which you are signing this lease/commencing occupancy. If such a child resides or will reside in the unit, the owner of the building is required to perform an annual visual inspection of the unit to determine the presence of lead-based paint hazards. IT IS IMPORTANT THAT YOU RETURN THIS FORM TO THE OWNER OR MANAGING AGENT OF YOUR BUILDING TO PROTECT THE HEALTH OF YOUR CHILD. If you do not respond to this notice, the owner is required to attempt to inspect your apartment to determine if a child under six years of age resides there. If a child under six years of age does not reside in the unit now, but does come to live in it at any time during the year, you must inform the owner in writing immediately. If a child under six years of age resides in the unit, you should also inform the owner immediately at the address below if you notice any peeling paint or deteriorated subsurfaces in the unit during the year. Please complete this form and return one copy to the owner or his or her agent or representative when you sign the lease/commence occupancy of the unit. Keep one copy of this form for your records. You should also receive a copy of a pamphlet developed by the New York City Department of Health and Mental Hygiene explaining about lead-based paint hazards when you sign your lease/commence occupancy. CHECK ONE: A child under six years of age resides in the unit. A child under six years of age does not reside in the unit. _________________________________ (Occupant signature) Print occupant's name, address and apartment number:________________________ _______________________________________________________________ (NOT APPLICABLE TO RENEWAL LEASE) Certification by owner: I certify that I have complied with the provisions of §27-2056.8 of Article 14 of the Housing Maintenance Code and the rules promulgated thereunder relating to duties to be performed in vacant units, and that I have provided a copy of the New York City Department of Health and Mental Hygiene pamphlet concerning lead-based paint hazards to the occupant. ____________________________ (Owner signature) RETURN THIS FORM TO: _________________________________________ _______________________________________________________________ OCCUPANT: KEEP ONE COPY FOR YOUR RECORDS OWNER COPY/OCCUPANT COPY American LegalNet, Inc. www.FormsWorkflow.com