Owner (Print) _____________________________________________________________________________
Tenant/s (Print) ___________________________________________________________________________
Property Address __________________________________________________________________________
1. NOTICE: Fungal contaminants (molds) may exist in the Property of which the Owner or his Agent are
unaware. These contaminants generally grow in places where there is excessive moisture, such as where
leakage may have occurred in roofs, pipes, walls, plant pots, or where there has been flooding. A
professional home inspection may or may not disclose fungal contaminants.
2. OWNER DISCLOSURE: To the best of Owner's knowledge:
Has the property had water damage? Yes No
If yes, has the water damage been repaired? Yes No
Has the property had a mold problem? Yes No
If yes, has the mold been remediated? Yes No
If there has been water damage or a mold problem, even if remediated, explain the problem and
repair/remediation ___________________________________________________________________
3. TENANT(S) DUTY TO INSPECT: Tenant(s) hereby assumes responsibility to conduct whatever
inspections Tenant(s) deems necessary to inspect the Property for mold contamination. Companies able to
perform such inspections can be found in the yellow pages under "Environmental and Ecological
4. RELEASE OF LIABILITY. Tenant(s) agrees to rely solely on inspections conducted by Tenant(s) and
professionals retained by Tenant(s). Tenant(s) herby releases and discharges all agents and brokers
involved in this transaction from any liability in conjunction with mold contamination of the Property.
Furthermore, except for any express misrepresentations by Owner in paragraph 2 herein, Tenant(s) hereby
releases and discharges Owner from any liability in conjunction with mold contamination of the Property
or any resulting damage the Tenant(s) may suffer. #
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