State of Ohio Applicant's Affidavit (Odometer Reading Disclosure Statement)State of Ohio Applicant's Affidavit (Odometer Reading Disclosure Statement)
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State of Ohio Applicant's Affidavit

Odometer Reading Disclosure Statement
(Type or Print in Ink)

Erasures & Alterations void this statement
Notice to applicant for certificate of title: You are required by law to enter all information required herein, including
the odometer reading of this motor vehicle in the affidavit immediately following. The making of a false statement
under oath or affirmation is in violation of section 2921.12 of the Ohio Revised Code and is punishable by six months
imprisonment and a fine of up to one Thousand dollars, or both.

State of Ohio,

County SS:

Year

Date

Mfr's serial no.
Model

Make
Body

Motor no.

type
Purchaser's name

Check one of the following statements. I(We) certify that:
I(We) have made every effort possible and cannot locate the previous owner of the above
described motor vehicle to obtain the odometer statement required by Section 4505.06 of the
Ohio Revised Code
I(We) obtained ownership of the above described motor vehicle by operati