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Kansas Department of Revenue

Odometer Disclosure Statement
Title Number

State Title Issued

Check the Appropriate Box
Original odometer disclosure statement for vehicle
Correction to odometer disclosure statement
Odometer statement for transfer of vehicle without title (legal affidavit or court document)

Federal and State law 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.
Transferor’s printed name

certify that the odometer now reads
mileage is:

miles To the best of my knowledge, the

Check the Appropriate Box
Actual mileage
In excess of its mechanical limits
Not the actual mileage (Warning, odometer discrepancy)

Vehicle Information:



Body Style

Vehicle Identification Number
Transferor’s Signature


Transferor’s Hand Printed Name
Transferor’s Address
Transferee’s Signature
Transferee’s Hand Printed Name
Transferee’s Address