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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.
I,

(Name of person making disclosure)

(Print)
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.
WARNING-ODOMETER DISCREPANCY.
MAKE
MODEL

BODY TYPE

VEHICLE IDENTIFICATION NO.

YEAR

TRANSFEROR'S SIGNATURE (SELLER)
TRANSFEROR'S PRINTED NAME REQUIRED
TRANSFEROR'S STREET ADDRESS
CITY

STATE

ZIP

DATE OF DISCLOSURE STATEMENT
TRANSFEREE'S SIGNATURE (BUYER)
TRANSFEREE'S PRINT