J-0200000-05 Clearance Receipt Acknowledgement Form Final 2-13-18.pdf

1200 First Street NE, 5th Floor, Washington, DC 20002 | (202) 535-2600 | doee.dc.gov February 13, 2018

GOVERNMENT OF THE DISTRICT OF COLUMBIA

Department of Energy and Environment

Lead-Safe and Healthy Housing Division Lead Compliance and Enforcement Branch

Receipt of Clearance Report

ACKNOWLEDGEMENT FORM

20 DCMR §§ 3314.1(b) and 3314.2(b) (form required)

20 DCMR §§ 3318.5 and 3318.6 (form optional)

A property owner (landlord) is required to provide this form and a lead clearance report to a prospective or current tenant who informs the landlord that a pregnant woman or child under six years old will reside in or regularly visit the rental unit. If the Department orders a landlord to eliminate lead-based paint hazards, the landlord is required to provide a clearance report to the tenant and may ask the tenant to sign this form. By signing the form, the tenant is acknowledging that he or she received the lead clearance report.

ADDRESS OF PROPERTY, INCLUDING UNIT # IF ANY:

Prospective or Current Tenant’s Acknowledgement

In keeping with the provisions of the Lead-Hazard Prevention and Elimination Act of 2008, as amended (D.C. Law 17-381; D.C. Official Code § 8-231.01 et seq.), I ________________________________ , confirm that I have received a lead clearance report, dated ___________________, for the property address specified above.

I received the clearance report on (insert date):________________________ .

Prospective or Current Tenant’s Signature Date