Free odometer disclosure statement 33
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84-001-1139 (5/12)

ODOMETER DISCLOSURE STATEMENT
Federal law (and State law, if applicable) requires that you state the mileage upon transfer of ownership. Failure
to complete or making a false statement may result in fines and/or imprisonment.
Complete disclosure form below and return to lessor.
I,
the odometer now reads

(lessee's name, Print) state that
(no tenths).

Check ONE item only:
(1) I hereby certify that to the best of my knowledge the odometer reading as stated above reflects the
actual mileage of the vehicle described below.
(2) I hereby certify that to the best of my knowledge the odometer reading reflects the amount of mileage in
excess of its mechanical limits.
(3) I hereby certify that the odometer reading is NOT the actual mileage.
WARNING: ODOMETER DISCREPANCY.
YEAR

MAKE

MODEL

BODY TYPE

VEHICLE IDENTIFICATION NUMBER

ACCOUNT NO.

LESSEE'S NAME AND ADDRESS

DATE OF STATEMENT (CURRENT DATE)

LESSEE'S SIGNATURE

X

CO-LESSEE'S NAME AND ADDRESS

DATE OF STATEMENT (