Free odometer disclosure statement 45Free odometer disclosure statement 45
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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.
Make Model Body Type
Vehicle Identification Number (VIN)
Signature of Transferor (Seller): ________________________________
Transferor’s (Seller’s) Information
Transferor’s Name (Please Print):
Street Address:
City: State: Zip:
Transferee’s (Buyer’s) Inf