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Enforcement in New England

Lead-Based Paint Disclosure Rule
Tip/Complaint Form

Fields in red are required.

Directions: Complete as much as possible.

1.

(a.) Name, Address, and Telephone Number of Alleged Violator(s)

Title:
Name:
Street:
City:
State:
ZIP:
Phone:
Alternate Phone:

Did the sale or rental involve a Seller's Agent or Lessor's Agent?

Agent Name:
Street:
City: State: ZIP:
Phone:
Alternate Phone:

(b.) Address of Sale or Rental Property

Street:
City: State: ZIP:
Phone:

(c.) Your Name, Address, and Telephone Number

You are a: if other:
Name:
Street:
City: State: ZIP:
Phone:
Alternate Phone:
E-mail:

 

2. General Information

(a.) Was the residence built before 1978:
   
(b.) Do children currently live in the residence?
   
(c.) If yes, what are their ages?
   
(d.) Are there children with elevated blood lead levels at this address?
   
(e.) Type of Housing: If other:

 

3. Sales Transaction

Date of the Purchase & Sale Agreement (i.e., date the Buyer became obligated to purchase the property):

 

4. Rental Transaction

(a.) Is the lease agreement written or unwritten? Written Unwritten
   
(b.) Date of Initial Lease:
   
(c.) How long has the Tenant resided in the unit?
   
(d.) How many units are in the Tenant's building?
   
(e.) Number of pre-1978 residential units owned by Lessor or managed by Agent:

 

5. Lead Disclosure

(a.) Did the Buyer/Tenant receive any information about lead-based paint/lead-based paint hazards?
   
(b.) Did the Buyer/Tenant receive an EPA-approved lead hazard information pamphlet?

 

6. Comments

 

 

Serving Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont, & 10 Tribal Nations

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