DigiSign Verified - 317eea62-8f6f-4e37-89f7-54f21fcf1091 This document has legal consequences. If you do not understand it, consult your attorney. The text of this form may not be altered in any manner without written acknowledgement of all parties. Form # 2049
©ST. LOUIS REALTORS® Approved by Counsel for St. Louis REALTORS® To be used exclusively by REALTOR® members of St. Louis REALTORS® and those issued a use license by St. Louis REALTORS®
07/25
DISCLOSURE OF INFORMATION ON LEAD-BASED PAINT AND/OR LEAD-BASED PAINT HAZARDS 1
516 Warder Ave, University City, MO 63130 PROPERTY: ____________________________________________________________________________________________________________
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Lead Warning Statement Every Buyer of any interest in residential real property on which a residential dwelling was built prior to 1978 is notified that such property may present exposure to lead from lead-based paint that may place young children at risk of developing lead poisoning. Lead poisoning in young children may produce permanent neurological damage, including learning disabilities, reduced intelligence quotient, behavioral problems, and impaired memory. Lead poisoning also poses a particular risk to pregnant women. The seller of any interest in residential real property is required to provide Buyer with any information on lead-based paint hazards from risk assessments or inspections in the seller’s possession and notify the buyer of any known lead-based paint hazards. A risk assessment or inspection for possible lead-based paint hazards is recommended prior to purchase. Seller’s Disclosure (a) Presence of lead-based paint and/or lead-based paint hazards (check one below): Seller has no knowledge of lead-based paint and/or lead-based paint hazards 4 in the housing Known lead-based paint and/or lead-based paint hazards are present in the housing (explain): ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ (b) Records and reports available to Seller (check one below): 4 Seller has provided the Buyer with all available records and reports pertaining to lead-based paint and/or lead-based paint hazards in the housing (list all documents below): ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Seller has no reports or records pertaining to lead-based paint and/or lead-based paint hazards in the housing. Buyer’s Acknowledgment (initial appropriate blanks)
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Received a 10-day opportunity (or mutually agreed upon period) to conduct a risk assessment or inspection of the presence of lead-based paint or lead-based hazards; or Waived the opportunity to conduct a risk assessment or inspection for the presence of lead-based paint and/or lead-based paint hazards. Agent’s Acknowledgment (initial) _________ Agent has informed Seller of Seller’s obligations under 42 U.S.C. 4852d and is aware of his/her responsibility to ensure compliance. ES (To be completed by listing agent or if not listed, agent assisting Buyer.) 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.
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_______________________________________________________ BUYER SIGNATURE DATE
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_______________________________________________________ Buyer Printed Name
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_______________________________________________________ BUYER SIGNATURE DATE
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_______________________________________________________ Buyer Printed Name
Emma Gaines ________________________________________________________ Seller Printed Name
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_______________________________________________________ BUYER’S AGENT SIGNATURE DATE
________________________________________________________ 07/26/2025 LISTING AGENT SIGNATURE DATE
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Elizabeth Southern _______________________________________________________ ________________________________________________________ Buyer’s Agent Printed Name Listing Agent Printed Name (NOTE: Any reference to Agent also includes a licensee acting as a Transaction Broker)
_________ __________ Buyer has received copies of all information listed above. (leave blank if none provided to Buyer.) _________ __________ Buyer has received the pamphlet Protect Your Family From Lead in Your Home. Buyer has (check one below):
Created by Elizabeth W. Southern with SkySlope® Forms
Brandon Dixon ________________________________________________________ SELLER SIGNATURE
07/26/2025
DATE
Brandon Dixon ________________________________________________________ Seller Printed Name
Emma Gaines ________________________________________________________ SELLER SIGNATURE
07/29/2025
DATE
Elizabeth Southern