DAQ-2024-008105

Sample Pre-Renovation Form Form Approved OMB No. 2070-0195 Expires 2/29/24
This sample form may be used by firms to document compliance with the requirements of the Federal Lead-
Based Paint Renovation, Repair, and Painting Program.
Occupant Confirmation
Pamphlet Receipt
___ I have received a copy of the lead hazard information pamphlet informing me of the potential risk of the
lead hazard exposure from renovation activity to be performed in my dwelling unit. I received this
pamphlet before the work began.
Printed Name of Owner-occupant
Signature of Owner-occupant Signature Date
Renovator’s Self Certification Option (for tenant-occupied dwellings only)
Instructions to Renovator: If the lead hazard information pamphlet was delivered but a tenant signature was not
obtainable, you may check the appropriate box below.
___ Declined – I certify that I have made a good faith effort to deliver the lead hazard information pamphlet
to the rental dwelling unit listed below at the date and time indicated and that the occupant declined to
sign the confirmation of receipt. I further certify that I have left a copy of the pamphlet at the unit with
the occupant.
___ Unavailable for signature – I certify that I have made a good faith effort to deliver the lead hazard
information pamphlet to the rental dwelling unit listed below and that the occupant was unavailable to
sign the confirmation of receipt. I further certify that I have left a copy of the pamphlet at the unit by
sliding it under the door or by (fill in how pamphlet was left).
Printed Name of Person Certifying Delivery Attempted Delivery Date
Signature of Person Certifying Lead Pamphlet Delivery
Unit Address
Note Regarding Mailing Option –– As an alternative to delivery in person, you may mail the lead
hazard information pamphlet to the owner and/or tenant. Pamphlet must be mailed at least 7 days
before renovation. Mailing must be documented by a certificate of mailing from the post office.
25