ODOMETER DISCLOSURE STATEMENT
To be competed by Transferor (Seller)
Federal law (and State law, if applicable) 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.
I, _________________, state that the odometer now reads _________ miles and to the best of my
knowledge that it reflects the actual mileage of the vehicle described below, unless one of the following
statements is checked.
(__) I hereby certify that to the best of my knowledge the odometer reading reflects the amount of
mileage in excess of its mechanical limits.
(__) I hereby certify that the odometer reading is NOT the actual mileage.
WARNING – ODOMETER DISCREPANCY.
Make Model Body Type
Vehicle Identification Number (VIN)
Signature of Transferor (Seller): ________________________________
Transferor’s (Seller’s) Information
Transferor’s Name (Please Print):
City: State: Zip:
Transferee’s (Buyer’s) Inf