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2. I attest as follows:
4. • I will provide a copy of the City of Buffalo Lead Paint Notice Form OR include the federal lead-based paint disclosure form to all tenants who move into the dwelling unit[s] after any current tenant vacates
6. • I am familiar with and will utilize lead safe practices when painting, renovating, or repairing the property
8. • Before I, or any agent acting on my behalf, engages in any repair, remodeling, or maintenance of any interior space that is six (6) square feet or more or exterior surfaces of twenty (20) square feet or more, I will provide the HUD/EPA pamphlet pertaining to lead paint to tenants residing in the dwelling units
10. • I understand that pursuant to City of Buffalo Code 264-14, the City of Buffalo or its representatives may inspect my property on its exterior, interior, or both, for lead paint violations or hazards
12. • I understand that if the City of Buffalo determines that a lead paint violation or hazard exists, the City of Buffalo will require the violation or hazard be remediated in a safe and timely manner. In some instances, the City of Buffalo may require that the work be performed by an EPA accredited contractor
14. • I understand that if the lead paint violation or hazard is not remediated in a manner satisfactory to the City of Buffalo, I may be fined, lose my rental registration certificate and be unable to rent my unit(s), and be subject to other action as permitted by law.
16. First Name *
17. Last Name *
19. Rental Property Address Number*
20. Rental Property Address Street*
22. Do you own additional rental properties?

    1. Yes
    2. No
24. Rental Property Address Number 2*
25. Rental Property Address Street 2
27. Rental Property Address Number 3
28. Rental Property Address Street 3
30. Rental Property Address Number 4
31. Rental Property Address Street 4
33. City
34. State
35. Zip Code
37. My building has
    -- Select One --1 Unit2 Units
39. Current tenants were notified of the potential of lead paint hazard by [check one]:

    1. Personal delivery of the City of Buffalo Lead Paint Notice Form by myself
    2. Personal delivery of the City of Buffalo Lead Paint Notice Form by a property manager or agent acting on my behalf
    3. Certified Mail of the City of Buffalo Lead Paint Notice Form
    4. Federal lead-based paint disclosure form in the Property’s Lease agreement
41. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
43. Electronic Signature
Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit

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