ODOMETER DISCLOSURE STATEMENT
Federal and State law require that you state the mileage upon transfer of ownership.
Failure to complete or providing a false statement may result in fines and/or
I, ______________________ (SELLER’S NAME, PRINT) state that the odometer now
reads ______________________ miles (NO TENTHS) and to the best of my
knowledge that it reflects the actual mileage of the vehicle described below, unless one
of the following statements is checked.
☐ - (1) I hereby certify that the odometer reading reflects the amount of mileage in
excess of its mechanical limits
☐ - (2) I hereby certify that the odometer reading is not the actual mileage. WARNING –
MAKE ______________ BODY STYLE ______________ YEAR ______________
MODEL ______________ VIN ______________________________________
LAST PLATE STATE ______________ LAST PLATE NUMBER ______________
SELLER’S SIGNATURE _________________ SELLER’S NAME _________________
SELLER’S ADDRESS ___________