TENNESSEE DEPARTMENT OF REVENUE
ODOMETER DISCLOSURE STATEMENT
FEDERAL and STATE LAW requires that you state the mileage in connection with the transfer of ownership. Failure to
complete or providing a false statement may result in fines and/or imprisonment.
SELLER OR TRANSFEROR’S NAME (PLEASE PRINT)
certify to the best of my knowledge that the odometer reading on the vehicle described below is the actual mileage of the
vehicle unless one of the following statements is checked:
ODOMETER READING (NO TENTHS)
I hereby certify that the mileage st ated is in excess of the mechanical limits of the odometer.
The odometer reading is not the actual mileage. WARNING - ODOMETER DISCREPANCY.
VEHICLE IDENTIFICATION NUMBER
SELLER OR TRANSFEROR’S ADDRESS
SELLER OR TRANSFEROR’S SIGNATURE
DATE OF THIS STATEMENT
BUYER OR TRANSFEREE’S NAME (PLEASE PRINT)
BUYER OR TRANSFEREE’S ADDRESS
BUYER OR TRANSFEREE’S SIGNATURE