Free form

Renovate Right pamphlet acknowledgment template

Use this template to record that a recipient got the Renovate Right pamphlet before work began. It follows EPA's Sample Pre-Renovation Form and the contents listed in 40 CFR 745.84(d). You can type in the fields and print the page. This page does not send or save what you type.

How to use it

Deliver the pamphlet no more than 60 days before renovation begins. Have each recipient complete Part 1 before work starts. In a rental, that means the owner or the owner's agent, and an adult occupant on a separate copy. Use a separate process for common-area notices.

Use Part 2 only for a rental occupant or a child-occupied facility representative, when the pamphlet was delivered but no signature could be obtained. It is not an option for the owner. Keep the signed form for at least 3 years after completion, or longer if another rule requires it.

The acknowledgment can also be part of your contract. It must be in the same language as the contract or, for non-owner-occupied housing, the same language as the lease or the pamphlet. This template is in English, so it may not fit every job.

Renovate Right pamphlet acknowledgment

Not an official EPA form. Adapted by RRP Central from EPA's sample form. General information, not legal advice.

Renovation firmPlanned start dateAddress of unit or facility, including unit number

Part 1. Confirmation of receipt

I received a copy of the pamphlet Renovate Right: Important Lead Hazard Information for Families, Child Care Providers and Schools before the renovation started. It tells me about the potential risk of lead hazard exposure from renovation activity.

I am signing as:

OwnerOwner's agent or property managerAdult occupantAdult representative of child-occupied facility

Printed nameSignature dateSignature

Part 2. Firm self-certification (rental occupants and facility representatives only)

To be completed by the firm if the pamphlet was delivered but a signature could not be obtained.

I certify that the pamphlet was delivered to the address above and that the firm could not obtain a written acknowledgment.

Reason:

Occupant or representative declined to signNo adult occupant or representative available

Other reasonDate of deliveryMethod of delivery (for example, left with occupant, under the door)Name(s) of person(s) who delivered the pamphletPrinted name of firm representativeSignature dateSignature of firm representative

Mailing option

Instead of delivery in person, the pamphlet may be mailed to the owner or occupant. It must be mailed at least 7 days before renovation, and the mailing must be documented with a certificate of mailing from the post office. Keep the certificate with this job.

Sources & scope

This page covers the federal RRP baseline. State, Tribal, local, HUD, or other applicable requirements may add or change steps, so check the program administering your work. This is general information, not legal advice. Published by RRP Central, a commercial recordkeeping tool. We are not affiliated with or endorsed by EPA.

Next, read the pamphlet delivery guide, or get the free recordkeeping checklist.