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.
state that the odometer (of the vehicle described below) now
PRINT TRANSFEROR’S NAME
(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.
VEHICLE ID NUMBER
TRANSFEROR’S PRINTED NAME (SELLER)
TRANSFEROR’S STREET ADDRESS
DATE OF STATEMENT
TRANSFEROR’S SIGNATURE (SELLER)
PRINTED NAME OF TRANSFEROR
TRANSFEREE’S PRINTED NAME (BUYER)