Department of Revenue
Division of Vehicles Topeka,
ODOMETER DISCLOSURE STATEMENT
Title issued by state of
Original odometer disclosure statement for vehicle on title listed above.
Correction to odometer disclosure statement for vehicle listed below.
Odometer statement for transfer of vehicle without title (legal affidavit/court document).
Federal/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 name – please print)
certify that the odometer now reads
(no tenths) miles.
To the best of my knowledge, the mileage is:
ONLY ONE BOX MUST BE CHECKED
(2) In excess of its mechanical limits
(1) Actual mileage
(3) NOT the actual
WARNING . . . ODOMETER DISCREPANCY
*** Transferor – Seller; Transferee – Buyer ***
Vehicle Identification Number
Date of Statement