Free odometer disclosure statement 13
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ODOMETER DISCLOSURE STATEMENT

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

state that the odometer (of the vehicle described below) now
PRINT TRANSFEROR’S NAME

reads
(no tenths) miles 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 to the best of my knowledge 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 - ODOMETER DISCREPANCY.
MAKE

BODY TYPE

MODEL

VEHICLE ID NUMBER

YEAR

TRANSFEROR’S PRINTED NAME (SELLER)
TRANSFEROR’S STREET ADDRESS
CITY

STATE

ZIP CODE

DATE OF STATEMENT

TRANSFEROR’S SIGNATURE (SELLER)

X
PRINTED NAME OF TRANSFEROR

TRANSFEREE’S PRINTED NAME (BUYER)
TRANS