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leaptodigital.com 2.30.3 <br />SAMPLE PRE-RENOVATION FORM <br />This sample form may be used by renovation firms to document compliance with the Federal pre-renovation education and <br />renovation, repair, and painting regulations. <br />Occupant confirmation <br />Pamphlet Receipt <br />☐ I have received a copy of the lead hazard information pamphlet informing me of the potential risk of the lead hazard <br />exposure from renovation activity to be performed in my dwelling unit. I received this pamphlet before the work began. <br />Printed Name of Owner-occupant Fred Jeanette Slaski/Spence <br />Fred Jeanette Slaski/Spence <br />10/08/2025 <br />Date <br />Renovator’s Self Certification Option (for tenant-occupied dwellings only) <br />Instructions to Renovator: If the lead hazard information pamphlet was delivered but a tenant signature was not obtainable, <br />you may check the appropriate box below. <br />☐ Declined – I certify that I have made a good faith effort to deliver the lead hazard information pamphlet to the rental <br />dwelling unit listed below at the date and time indicated and that the occupant declined to sign the confirmation of receipt. I <br />further certify that I have left a copy of the pamphlet at the unit with the occupant. <br />☐ Unavailable for signature – I certify that I have made a good faith effort to deliver the lead hazard information pamphlet to <br />the rental dwelling unit listed below and that the occupant was unavailable to sign the confirmation of receipt. I further certify <br />that I have left a copy of the pamphlet at the unit by sliding it under the door or by (fill in how pamphlet was left). <br />Printed Name of Person Certifying Delivery Alex Miller <br />Attempted Delivery Date 10/08/2025 <br />Signature of Person Certifying Lead Pamphlet Delivery <br />10/08/2025 <br />Date <br />Unit Address <br />721 Forest Ave <br />South Bend IN 46616 <br />Note Regarding Mailing Option — As an alternative to delivery in person, you may mail the lead hazard information pamphlet <br />to the owner and/or tenant. Pamphlet must be mailed at least seven days before renovation. Mailing must be documented by <br />a certificate of mailing from the post office. <br />Page 18 of 23