Free odometer disclosure statement 16
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Odometer Disclosure Statement
ADDRESS 1
101 E NORTH TEMPLE ST
SALT LAKE CITY UT 0000-0000
TELEPHONE (801) 000-0000
Federal law (and state law where applicable) requires that you state the mileage upon transfer of ownership of a
vehicle. Failure to complete, or providing a false statement, may result in fines and/or imprisonment.
Seller’s Instructions
1. Prepare this form in the presence of the transferee
(buyer) where possible.
2. Complete the transferor’s (seller’s) section
and sign.

Buyer’s Instructions
1. Complete the transferee’s (buyer’s) section
and sign.
2. Give or mail the pink copy to the transferor
(seller).

3. If this document must be mailed to the transferee
(buyer) for completion, make a photocopy and use the
copy until the pink copy is returned.
4. Forward the pink copy with the buyer’s check to Fleet
Administration.
3. Present the canary copy when applying for the title in your
name.
4. Keep the white copy for your records.

Statement

I,

(Print name of transferor, or