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Utah State Tax Commission

Rev. 11/12

Odometer Disclosure Statement
Division of Motor Vehicles · PO Box 30412, Salt Lake City, UT 84130
· Telephone801-297-7780 or 1-800-368-8824

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Section 1 - Transferor Information
Transferor’s name (print last, first, middle initial, or business name)
Street address



Section 2 - Vehicle Information


Vehicle/Hull Identification Number (VIN/HIN)

Body type

Zip code

Section 3 - Odometer Disclosure
Federal and State law require that you furnish to the transferee a written odometer disclosure statement upon transfer of ownership.
Failure to complete or providing a false statement may result in fines and/or imprisonment. Both the transferor and the transferee shall
retain a legible copy of the odometer disclosure statement for not less than four years.
I certify that the odometer reading: (check one)
Reflects the actual mileage.
Enter odometer reading (no tenths)

Reflects the mileage i