Odometer Disclosure Statement
ODOMETER DISCLOSURE STATEMENT
Federal Regulations require you to state the mileage upon transfer of ownership of a motor vehicle. Failure to complete
or providing a false statement may result in fines and/or imprisonment.
(Name of person making disclosure)
hereby state that the odometer now reads
(no tenths) miles and to
the best of my knowledge 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.
VEHICLE IDENTIFICATION NO.
TRANSFEROR'S SIGNATURE (SELLER)
TRANSFEROR'S PRINTED NAME REQUIRED
TRANSFEROR'S STREET ADDRESS
DATE OF DISCLOSURE STATEMENT
TRANSFEREE'S SIGNATURE (BUYER)