Free odometer disclosure statement 47
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T-107 (Rev. 08-2005)

ODOMETER DISCREPANCY AFFIDAVIT
Seller(s)’/Transferor(s)’ Statement of Facts
This is to certify that on ____________________, I/we_________________________________________________________
(Date)

(Seller(s)’/Transferor(s)’ Full Legal Name(s)

__________________________________________________________________________________________________________________
(Seller(s)’/Transferor(s)’ Address)

sold or transferred the ownership of the following described vehicle: ________________

____________________________

(Year Model & Make)

(Vehicle Identification Number)

to: __________________________________________________________________________________________________
(Purchaser(s)’/Transferee(s)’ Full Legal Name(s) & Address)

* This is to certify that to the best of my knowledge that at the time that I sold or transferred the ownership of this vehicle, the
odometer mileage reading on this vehicle was ____________________ (No Tenths) and was the total actual mileage the