Florida Rental Application 4
Florida Rental Application 1
Florida Rental Application 2
Florida Rental Application 3
Florida Rental Application 4
Florida Rental Application 1

Florida Rental Application

    Rental applications can provide the landlords with expressive information related to the people that have applied, which can be tallied and checked across background check sites for confirmation. To find the best match for renting out your property in Florida, you need to offer appropriate rental applications with extensive details. Rather than searching for or designing from zero a proper rental application format across the Internet, we have set up a simple and effective Florida rental application template for the residents there to utilize.

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Florida Rental Application

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Are you looking for information on the Florida rental application? Do you want to know what the state-specific regulations to follow when making a Florida rental application are? Are you interested in knowing what should be included in the Florida rental application form?

Keep reading to know every detail about the Florida rental application.

What Is a Florida Rental Application?

Florida rental application is the key-step that the landlords take to verify the tenants before allowing them into their property. This form is a part of the renting procedure where the tenant fills-in the required information about them.

Where the Florida rental application form helps the landlords to know their probable tenants better. On the other hand, there are strict regulations for the landlords about the questions they may ask in the form. Therefore, it is important for the landlords to make the rental application form carefully.

The Florida rental application form can have an application fee, where the amount of the fee depends on the landlord. However, this application fee is conditionally non-refundable under Florida law.

The layout of the standard Florida rental application form is simple and easy to understand, fill, and review. This makes things easier for both the landlord and the tenant, especially with handling sensitive information.

Moreover, the landlords can demand the applicants to attach a credit report with the application form. Additionally, a landlord can ask the applicants about their background history, job details, sources of income, and their criminal history.

The applicants must provide correct information on the form since the landlord scrutinizes them on the basis of this information. The employment details help the landlords pick the applicant who will be able to pay the rent easily.

However, the information that landlords demand differs from person to person. That is, some landlords may require minimal information from the applicant while some may go into detailed interviews.

Verify Your Tenants By Using Our Florida Rental Application Example

Get access to CocoSign’s Florida Rental Application for property rental. These rental applications contain terms and sections legally approved by leading attorneys. Download, save and share the rental application as you require.

Get access to your FREE copy of the Florida rental agreement.

Why Is It Important to Have a Florida Rental Application?

Security purposes count as the biggest concerns when someone rents out a property. It is natural since they have put in their money and investment in the property that is to rent. Therefore, having a reliable tenant who doesn’t only follows the rules but also keeps good care of premises is important.

These applications enable the landlords to learn more about a person before hiring them as a tenant in their property. A landlord can see if an applicant will be able to pay the due rent on time or not.

Likewise, the rental histories and the reasons for leaving previous residences reveal about the conduct of the applicant with landlords. This ensures that the applicant won’t cause trouble to the landlord and will take care of the property. To conclude, the Florida rental application is important for a landlord to protect their investment.

What Are Included in a Florida Rental Application?

There are certain things that are important to include in a Florida rental application form. These include:

Description of the Rental Property/Unit:

The landlord must describe the property or the unit that is to rent accurately. The standard description includes the complete address of the unit, including its number, street name, city, and state.

It is very important to list the correct address. This does not only help the tenants to locate and know about the property but also it helps in legal proceedings. In the case of any dispute, a landlord can get into trouble for not providing the correct address.

Personal Information:

A landlord can ask the applicants about their basic personal information. This includes the legal names, social security numbers, and details of associated family members. The landlords must ensure that the applicants provide their social security number. This helps to screen out the frauds.

Likewise, it is mandatory for applicants to provide their driver’s license number. For those who do not have a driver’s license, they must attach the state-issued id number. The landlord should also ask for the expiration date of both. Additionally, some landlords ask for the telephone numbers and emails from the applicants.

Rental History:

This section of the rental application form addresses the rental history of the applicant for the past 3 years. This requires the applicants to include their past 3 addresses and the duration that they lived at these addresses for.

Moreover, the landlord also demands the applicants to enter the contact number of their previous landlords. This helps them to know about any tenant issues the applicant may have caused them.

Employment History:

The landlord can demand the applicant to enter their employment history for 5 years, starting from their current job. The details of employment may include their salary, contact information of their supervisor, and the address of the company.

The employment history does not only tell the landlord about the social conduct of the applicant but also gives an estimate of whether they can bear the rent expenses or not.

Financial History:

The financial history of the applicant is as important as the employment details. This section includes the additional sources of income of the applicants like self-employment, child care, etc. Moreover, the applicant has to provide their bank account details, including the bank balance along with the account number.

Roommate Information:

This section includes information for every person who will reside in the property. Similar personal information as of the primary applicant is a must to include for all the roommates.

Personal References:

The state law of Florida requires the applicant to enter at least 2 personal references in the application form. This helps the landlord to confirm the information of the applicant with the references. The personal references are the persons whom the applicant knows and do not form their immediate family.

Applicant’s Vehicle Information:

The applicant must list the vehicle they own and its details. These details include the vehicle model, year, and license plate number. The state under which it is issued is also important to include.

Personal History:

The personal history of the applicant regarding criminal history, drug use, and other issues are very important to include. Some of the questions that a landlord may ask include:

  • Does the applicant smoke?
  • Has the applicant ever faced eviction?
  • Has the applicant ever gone bankrupt?
  • Has the applicant ever been a convicted felon?

Emergency Information:

The landlord may ask the applicant to provide the contact information of someone to contact at the time of emergency. This can be a close friend or relative of the applicant.

Regulations in Florida Governing Rental Applications

The state of Florida has its set of laws that govern Florida rental applications. These laws and regulations include:

  • The Florida state does not restrict the amount of application fee that the landlord may demand. However, it is a suggestion to not increase the fee more than an average out-of-pocket expense.
  • The landlords must keep the deposit and other fees that the tenants submit, separately. It should not co-mingle with the landlord’s money.
Verify Your Tenants By Using Our Florida Rental Application Example

Get access to CocoSign’s Florida Rental Application for property rental. These rental applications contain terms and sections legally approved by leading attorneys. Download, save and share the rental application as you require.

Get access to your FREE copy of the Florida rental agreement.


The Florida rental application is a tool for the landlords to pick the best applicant as their tenant to a property. However, this application form has some set of regulations from the state of Florida.

Moreover, it is important to handle it carefully since it has sensitive information about the applicants. The Florida rental application form is accessible on the CocoSign website, from where the users can pick them to use.




I. THE PARTIES. This Florida Month-to-Month Lease Agreement (“Agreement”) made this ________________, 20____ is between:


Landlord: _______________________ with a mailing address of _______________________, City of _______________________, State of _______________________ ("Landlord"), AND


Tenant(s): ______________________________________________ (“Tenant”).


Landlord and Tenant are each referred to herein as a “Party” and, collectively, as the "Parties."


NOW, THEREFORE, FOR AND IN CONSIDERATION of the mutual promises and agreements contained herein, the Tenant agrees to lease the Premises from the Landlord under the following terms and conditions:


II. LEASE TYPE. This Agreement shall be considered a month-to-month Lease. The Tenant shall be allowed to occupy the Premises on a month-to-month arrangement starting on ________________, 20____ and ending upon notice of ____ days from either Party to the other Party (“Lease Term”). It is recognized that the minimum termination period for the State of Florida is fifteen (15) days.


III. OCCUPANT(S). The Premises is to be occupied strictly as a residential dwelling with the following individual(s) in addition to the Tenant: (check one)


- ______________________________________________ (“Occupant(s)”)


- There are no Occupant(s).


IV. THE PROPERTY. The Landlord agrees to lease the described property below to the Tenant: (enter the property information)


a.)   Mailing Address: ________________, City of ________________, State of ________________.

b.)   Residence Type: Apartment House Condo Other: ________________

c.)   Bedroom(s): ____

d.)   Bathroom(s): ____


The aforementioned property shall be leased wholly by the Tenant (“Premises”).


V. PURPOSE. The Tenant and Occupant(s) may only use the Premises as: (check one)


- A residential dwelling only.


- A residential dwelling and: _______________________________________.


VI. FURNISHINGS. The Premises is: (check one)


- To be furnished with the following: _________________________________



- Not furnished.


VII. APPLIANCES. The Landlord shall: (check one)


- Provide the following appliances: __________________________________



- Not provide any appliances.


VIII. RENT. The Tenant shall pay the Landlord, in equal monthly installments, $________________ ("Rent"). The Rent shall be due on the ____ of every month (“Due Date”) and paid under the following instructions: _______________________________.


IX. NON-SUFFICIENT FUNDS (NSF CHECKS). If the Tenant pays the Rent with a check that is not honored due to insufficient funds (NSF): (check one)


- There shall be a fee of $____ per incident.


- There shall be no fee. 


X. LATE FEE. If Rent is not paid on the Due Date: (check one)


- There shall be a penalty of $____ due as One (1) Time Payment Every Day Rent is Late. Rent is considered late when it has not been paid within ____ day(s) after the Due Date.


- There shall be No Late Fee if Rent is late.


XI. FIRST (1ST) MONTH'S RENT. The Tenant is required to pay the first (1st) month's rent: (check one)


- Upon the execution of this Agreement.


- Upon the first (1st) day of the Lease Term.


XII. PRE-PAYMENT. The Tenant shall: (check one)


- Pre-Pay Rent in the amount of $________________ for the term starting on ________________, 20____ and ending on ________________, 20____. The Pre-Payment of Rent shall be due upon the execution of this Agreement.


- Not be required to Pre-Pay Rent.


XIII. PRORATION PERIOD. The Tenant: (check one)


- Shall take possession of the Premises before the start of the Lease Term on ________________, 20____ and agrees to pay $________________ for the proration period. The proration rate is calculated by the monthly Rent on a daily basis which shall be paid by the Tenant upon the execution of this Agreement.


- Shall not be taking possession of the Premises before the Lease Term.


XIV. SECURITY DEPOSIT. As part of this Agreement: (check one)


- The Landlord requires a payment in the amount of $________________ (“Security Deposit”) for the faithful performance of the Tenant under the terms and conditions of this Agreement. Payment of the Security Deposit is required by the Tenant upon the execution of this Agreement. The Security Deposit shall be returned to the Tenant within ____ days after the end of the Lease Term less any itemized deductions. This Security Deposit shall not be credited towards any Rent unless the Landlord gives their written consent.


- The Landlord does not require a Security Deposit as part of this Agreement.


XV. MOVE-IN INSPECTION. Before, at the time of the Tenant accepting possession, or shortly thereafter, the Landlord and Tenant: (check one)


- Agree to inspect the Premises and write any present damages or needed repairs on a move-in checklist.


- Shall not inspect the Premises or complete a move-in checklist.


XVI. PARKING. The Landlord: (check one)


- Shall provide ____ parking space(s) to the Tenant for a fee of $_____ to be paid at the execution of this Agreement on a monthly basis in addition to the rent. The parking space(s) are described as: _________________________________________.


- Shall NOT provide parking.


XVII. SALE OF PROPERTY. If the Premises is sold, the Tenant is to be notified of the new Owner, and if there is a new Manager, their contact details for repairs and maintenance shall be forwarded. If the Premises is conveyed to another party, the new owner: (check one)


- Has the right to terminate this Agreement by providing ___ days’ notice to the Tenant.


- Does not have the right to terminate this Agreement.


XVIII. UTILITIES. The Landlord shall provide the following utilities and services to the Tenant: _______________________________________________________________



Any other utilities or services not mentioned will be the responsibility of the Tenant.


XIX. EARLY TERMINATION. The Tenant: (check one)


- Shall have the right to terminate this Agreement at any time by providing at least ___ days’ written notice to the Landlord along with an early termination fee of $___________ (US Dollars). During the notice period for termination the Tenant will remain responsible for the payment of rent.


- Shall not have the right to terminate this Agreement. 


XX. SMOKING POLICY. Smoking on the Premises is: (check one)


- Permitted ONLY in the following areas: _____________________________.


- Prohibited on the Premises and Common Areas.


XXI. PETS. The Tenant: (check one)


- Shall have the right to have ___ pet(s) on the Premises consisting of __________________________________________________ [Types of Pets Allowed] that are not to weigh over ____ pounds. For the right to have pet(s) on the Premises the Landlord shall charge a fee of $___________ that is non-refundable refundable unless there are damages related to the pet. The Tenant is responsible for all damage that any pet causes, regardless of ownership of said pet and agrees to restore the Premises to its original condition at their expense.


- Shall not have the right to have pets on the Premises or in the common areas.


XXII. WATERBEDS. The Tenant: (check one)


- Shall have the right to use a waterbed on the Premises.


- Shall not have the right to use a waterbed on the Premises.


XXIII. NOTICES. Any notice to be sent by the Landlord or the Tenant to each other shall use the following addresses:


Landlord's / Agent's Address:




Tenant's Mailing Address: (check one)


- The Premises.


- Other. _______________________________________________________.


XXIV. AGENT/MANAGER. (check one)


- The Landlord does have a manager on the Premises that can be contacted for any maintenance or repair at:


Name: _______________________


Telephone (____) _____-______ E-Mail _____________________________


- The Landlord does not have a manager on the Premises although the Landlord can be contacted for any maintenance or repair at:


Telephone (____) _____-______ E-Mail _____________________________


XXV. POSSESSION. Tenant has examined the condition of the Premises and by taking possession acknowledges that they have accepted the Premises in good order and in its current condition except as herein otherwise stated. Failure of the Landlord to deliver possession of the Premises at the start of the Lease Term to the Tenant shall terminate this Agreement at the option of the Tenant. Furthermore, under such failure to deliver possession by the Landlord, and if the Tenant cancels this Agreement, the Security Deposit (if any) shall be returned to the Tenant along with any other pre-paid rent, fees, including if the Tenant paid a fee during the application process before the execution of this Agreement.


XXVI. ACCESS. Upon the beginning of the Proration Period or the start of the Lease Term, whichever is earlier, the Landlord agrees to give access to the Tenant in the form of keys, fobs, cards, or any type of keyless security entry as needed to enter the common areas and the Premises. Duplicate copies of the access provided may only be authorized under the consent of the Landlord and, if any replacements are needed, the Landlord may provide them for a fee. At the end of this Agreement all access provided to the Tenant shall be returned to the Landlord or a fee will be charged to the Tenant or the fee will be subtracted from the Security Deposit.


XXVII. SUBLETTING. The Tenant shall not be able to sublet the Premises without the written consent from the Landlord. The consent by the Landlord to one subtenant shall not be deemed to be consent to any subsequent subtenant.


XXVIII. ABANDONMENT. If the Tenant vacates or abandons the Premises for a time-period that is the minimum set by State law or seven (7) days, whichever is less, the Landlord shall have the right to terminate this Agreement immediately and remove all belongings including any personal property off of the Premises. If the Tenant vacates or abandons the Premises, the Landlord shall immediately have the right to terminate this Agreement.


XXIX. ASSIGNMENT. Tenant shall not assign this Lease without the prior written consent of the Landlord. The consent by the Landlord to one assignment shall not be deemed to be consent to any subsequent assignment. 


XXX. RIGHT OF ENTRY. The Landlord shall have the right to enter the Premises during normal working hours by providing at least twenty-four (24) hours notice in order for inspection, make necessary repairs, alterations or improvements, to supply services as agreed or for any reasonable purpose. The Landlord may exhibit the Premises to prospective purchasers, mortgagees, or lessees upon reasonable notice.


XXXI. MAINTENANCE, REPAIRS, OR ALTERATIONS. The Tenant shall, at their own expense and at all times, maintain premises in a clean and sanitary manner, and shall surrender the same at termination hereof, in as good condition as received, normal wear and tear excepted. The Tenant may not make any alterations to the leased premises without the consent in writing of the Landlord. The Landlord shall be responsible for repairs to the interior and exterior of the building. If the Premises includes a washer, dryer, freezer, dehumidifier unit and/or air conditioning unit, the Landlord makes no warranty as to the repair or replacement of units if one or all shall fail to operate. The Landlord will place fresh batteries in all battery-operated smoke detectors when the Tenant moves into the premises. After the initial placement of the fresh batteries it is the responsibility of the Tenant to replace batteries when needed. A monthly "cursory" inspection may be required for all fire extinguishers to make sure they are fully charged.


XXXII. NOISE/WASTE. The Tenant agrees not to commit waste on the premises, maintain, or permit to be maintained, a nuisance thereon, or use, or permit the premises to be used, in an unlawful manner. The Tenant further agrees to abide by any and all local, county, and State noise ordinances.


XXXIII. GUESTS. There shall be no other persons living on the Premises other than the Tenant and any Occupant(s). Guests of the Tenant are allowed for periods not lasting for more than 48 hours unless otherwise approved by the Landlord in writing.


XXXIV. COMPLIANCE WITH LAW. The Tenant agrees that during the term of the Agreement, to promptly comply with any present and future laws, ordinances, orders, rules, regulations, and requirements of the Federal, State, County, City, and Municipal government or any of their departments, bureaus, boards, commissions and officials thereof with respect to the premises, or the use or occupancy thereof, whether said compliance shall be ordered or directed to or against the Tenant, the Landlord, or both.



. If the Tenant fails to comply with any of the financial or material provisions of this Agreement, or of any present rules and regulations or any that may be hereafter prescribed by the Landlord, or materially fails to comply with any duties imposed on the Tenant by statute or State laws, within the time period after delivery of written notice by the Landlord specifying the non-compliance and indicating the intention of the Landlord to terminate the Agreement by reason thereof, the Landlord may terminate this Agreement. If the Tenant fails to pay rent when due and the default continues for the time-period specified in the written notice thereafter, the Landlord may, at their option, declare the entire balance (compiling all months applicable to this Agreement) of rent payable hereunder to be immediately due and payable and may exercise any and all rights and remedies available to the Landlord at law or in equity and may immediately terminate this Agreement.


The Tenant will be in default if: (a) Tenant does not pay rent or other amounts that are owed; (b) Tenant, their guests, or the Occupant(s) violate this Agreement, rules, or fire, safety, health, or criminal laws, regardless of whether arrest or conviction occurs; (c) Tenant abandons the Premises; (d) Tenant gives incorrect or false information in the rental application; (e) Tenant, or any Occupant(s) is arrested, convicted, or given deferred adjudication for a criminal offense involving actual or potential physical harm to a person, or involving possession, manufacture, or delivery of a controlled substance, marijuana, or drug paraphernalia under state statute; (f) any illegal drugs or paraphernalia are found in the Premises or on the person of the Tenant, guests, or Occupant(s) while on the Premises and/or; (g) as otherwise allowed by law.


XXXVI. MULTIPLE TENANT OR OCCUPANT(S). Each individual that is considered a Tenant is jointly and individually liable for all of this Agreement's obligations, including but not limited to rent monies. If any Tenant, guest, or Occupant(s) violates this Agreement, the Tenant is considered to have violated this Agreement. Landlord’s requests and notices to the Tenant or any of the Occupant(s) of legal age constitutes notice to the Tenant. Notices and requests from the Tenant or any one of the Occupant(s) (including repair requests and entry permissions) constitutes notice from the Tenant. In eviction suits, the Tenant is considered the agent of the Premise for the service of process.


XXXVII. DISPUTES. If a dispute arises during or after the term of this Agreement between the Landlord and Tenant, they shall agree to hold negotiations amongst themselves, in "good faith", before any litigation.


XXXVIII. SEVERABILITY. If any provision of this Agreement or the application thereof shall, for any reason and to any extent, be invalid or unenforceable, neither the remainder of this Agreement nor the application of the provision to other persons, entities or circumstances shall be affected thereby, but instead shall be enforced to the maximum extent permitted by law.


XXXIX. SURRENDER OF PREMISES. The Tenant has surrendered the Premises when (a) the move-out date has passed and no one is living in the Premise within the Landlord’s reasonable judgment; or (b) Access to the Premise have been turned in to Landlord – whichever comes first. Upon the expiration of the term hereof, the Tenant shall surrender the Premise in better or equal condition as it were at the commencement of this Agreement, reasonable use, wear and tear thereof, and damages by the elements excepted.


XL. RETALIATION. The Landlord is prohibited from making any type of retaliatory acts against the Tenant including but not limited to restricting access to the Premises, decreasing or cancelling services or utilities, failure to repair appliances or fixtures, or any other type of act that could be considered unjustified.



. A Waiver by the Landlord for a breach of any covenant or duty by the Tenant, under this Agreement is not a waiver for a breach of any other covenant or duty by the Tenant, or of any subsequent breach of the same covenant or duty. No provision of this Agreement shall be considered waived unless such a waiver shall be expressed in writing as a formal amendment to this Agreement and executed by the Tenant and Landlord.


XLII. EQUAL HOUSING. If the Tenant possesses any mental or physical impairment, the Landlord shall provide reasonable modifications to the Premises unless the modifications would be too difficult or expensive for the Landlord to provide. Any impairment(s) of the Tenant are encouraged to be provided and presented to the Landlord in writing in order to seek the most appropriate route for providing the modifications to the Premises.


XLIII. HAZARDOUS MATERIALS. The Tenant agrees to not possess any type of personal property that could be considered a fire hazard such as a substance having flammable or explosive characteristics on the Premises. Items that are prohibited to be brought into the Premises, other than for everyday cooking or the need of an appliance, includes but is not limited to gas (compressed), gasoline, fuel, propane, kerosene, motor oil, fireworks, or any other related content in the form of a liquid, solid, or gas.


XLIV. INDEMNIFICATION. The Landlord shall not be liable for any damage or injury to the Tenant, or any other person, or to any property, occurring on the Premises, or any part thereof, or in common areas thereof, and the Tenant agrees to hold the Landlord harmless from any claims or damages unless caused solely by the Landlord's negligence. It is recommended that renter's insurance be purchased at the Tenant's expense.


XLV. COVENANTS. The covenants and conditions herein contained shall apply to and bind the heirs, legal representatives, and assigns of the parties hereto, and all covenants are to be construed as conditions of this Agreement.


XLVI. PREMISES DEEMED UNINHABITABLE. If the Premises is deemed uninhabitable due to damage beyond reasonable repair the Tenant will be able to terminate this Agreement by written notice to the Landlord. If said damage was due to the negligence of the Tenant, the Tenant shall be liable to the Landlord for all repairs and for the loss of income due to restoring the Premises back to a livable condition in addition to any other losses that can be proved by the Landlord.


XLVII. FIRE PROTECTION. If the Premises is in a building over 3 stories high, the Landlord must provide and disclose to the Tenant initially moving into the building the availability or lack of availability of fire protection. If the Premises is over 3 stories high, the Tenant acknowledges the Landlord gave them this disclosure with their signature below in this Agreement.


XLVIII. RADON GAS. Per Florida law, the following statement must be included in this Agreement as awareness to the Tenant:


Radon is a naturally occurring radioactive gas that, when it has accumulated in a building in sufficient quantities, may present health risks to persons who are exposed to it over time. Levels of radon that exceed federal and state guidelines have been found in buildings in Florida. Additional information regarding radon and radon testing may be obtained from your county health department.


XLIX. DEPOSITS. Per Florida law, the following statement must be included in this Agreement as awareness to the Tenant:













L. LEAD PAINT. (check one)


- The Premises was built prior to 1978 and there is an attachment titled the ‘Lead-Based Paint Disclosure’ that must be initialed and signed by the Landlord and Tenant.


- The Premises was not built prior to 1978.


LI. GOVERNING LAW. This Agreement is to be governed under the laws located in the State of Florida.


LII. ADDITIONAL TERMS AND CONDITIONS. _______________________________




LIII. ENTIRE AGREEMENT. This Agreement contains all the terms agreed to by the parties relating to its subject matter including any attachments or addendums. This Agreement replaces all previous discussions, understandings, and oral agreements. The Landlord and Tenant agree to the terms and conditions and shall be bound until the end of the Lease Term.



Landlord's Signature ___________________________ Date: _____________


Print Name: __________________


Tenant’s Signature ___________________________ Date: _____________


Print Name: __________________


Tenant’s Signature ___________________________ Date: _____________


Print Name: __________________


Agent’s Signature ___________________________ Date: _____________


Print Name: __________________




Security Deposit: $____________


First (1st) Month's Rent: $____________


Parking Fee: $____________


Pet Fee(s): $____________


Pre-Payment of Rent: $____________


Proration Amount: $____________



Total Amount: $____________



















Disclosure of Information on Lead-Based Paint and/or Lead-Based Paint Hazards

  1. Lead Warning Statement

Housing build before 1978 may contain lead-based paint. Lead from paint, paint chips, and dust can pose health hazards if not managed properly. Lead exposure is especially harmful to young children and pregnant women. Before renting pre-1978 housing, landlords must disclose the presence of known lead-based paint and /or lead-based paint hazards in the dwelling. Tenants must also receive a federally approved pamphlet on lead poisoning prevention.

  1. Lessor’s Disclosure

(a)  Presence of lead-based paint and/or lead-based paint hazards (check one below):

- Known lead-based paint and/or lead-based paint hazards are present in the housing (explain): _______________________________________.

- Landlord has no knowledge of lead-based paint and/or lead-based paint hazards in the housing.

(b)  Records and reports available to the landlord (check one below)

- Landlord has provided the tenant with all available records and reports pertaining to lead-based paint and/or lead-based paint hazards in the housing (list documents below).

- Landlord has no reports or records pertaining to lead-based paint and/or lead-based paint hazards in the housing.

  1. Tenant’s Acknowledgement

- Tenant has received copies of all information listed above.

- Tenant has received the pamphlet “Protect Your Family From Lead in Your Home”.

  1. Broker’s Acknowledgement

- Broker has informed the tenant of the tenant’s obligations under 42 USC 4852(d) and is aware of his/her responsibility to ensure compliance.

  1. Certification of Accuracy

The following parties have reviewed the information above and certify, to the best of their knowledge, that the information they have provided is true and accurate.


Landlord's Signature ___________________________ Date: _____________


Print Name: __________________


Tenant’s Signature ___________________________ Date: _____________


Print Name: __________________


Tenant’s Signature ___________________________ Date: _____________


Print Name: __________________


Agent’s Signature ___________________________ Date: _____________


Print Name: __________________

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