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.
the odometer now reads
(lessee's name, Print) state that
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.
VEHICLE IDENTIFICATION NUMBER
LESSEE'S NAME AND ADDRESS
DATE OF STATEMENT (CURRENT DATE)
CO-LESSEE'S NAME AND ADDRESS
DATE OF STATEMENT (