Free odometer disclosure statement 41
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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 on 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

MODE
L

Vin

BOD TYPE
Y
YEA
R

SIGNATURE
PRINTED NAME REQUIRED
STREET ADDRESS
CITY

STATE

ZIP