Free odometer disclosure statement 46
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TC 96-5
Rev. 3/89
Transportation Cabinet
Division of Motor Vehicle Licensing

Odometer Disclosure
Statement
Federal Law 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.
, state that the odometer now reads

I,

(Transferor's name, Print)

(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 Number
Year
(Transferor's Signature)

Transferor's
Address
(Street)
(City)

(Zip Code)

(State)

Date of Statement
(Transferee's Signature)
(Printed Name)

Transferee's Name
Transferee's
Address
(S