| PRE-RENOVATION LEAD-BASED PAINT INFORMATION |
| PRE-RENOVATION LEAD-BASED PAINT INFORMATION
Refusal to Sign Form (Keep this form on file for 3 years.)
I certify that I have made a good faith effort to deliver the pamphlet, Protect Your Family From Lead In Your Home, to the unit listed below at the dates and times indicated, and that the occupant refused to sign the acknowledgment. I further certify that I have left a copy of the pamphlet at the unit with the occupant.
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