Free odometer disclosure statement 17Free odometer disclosure statement 17
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ODOMETER DISCLOSURE
STATEMENT

FORM

3019

INSTRUCTIONS ON REVERSE
YEAR

MAKE

TITLE NUMBER

Federal law (and State law, if
applicable) requires that you state the
mileage upon transfer of ownership.
Failing to complete or providing a
false statement may result in fines
and/or imprisonment.

VEHICLE IDENTIFICATION NUMBER

STATE

MODEL

BODY STYLE

If purchaser/seller is an agent/officer of a firm, record official position after printed name. The purchaser/seller
should retain a copy of this odometer disclosure statement. If “Warning, Odometer Discrepancy” is checked, the
seller must attach a statement explaining all facts regarding the discrepancy.
PURCHASER(S) NAME

DATE

(PRINTED OR TYPED)

ADDRESS
SELLER(S) (FIRM) NAME

DEALER NO.

(PRINTED OR TYPED)

ADDRESS
ODOMETER READING

I state that the odometer now reads the aforementioned miles and to
Mileage in excess of its mechanical limits
the best of my knowledge that it reflects the actual mileage of the
Mileage reading not actual
veh