Odometer Disclosure Certificate

Vehicle Information

Make

Model

Year

Body Type

Vehicle Identification Number (VIN)

Odometer Reading (No tenths)

Transferor (Seller) Information

Name (Printed)

Address

City

State

ZIP Code

Transferee (Buyer) Information

Name (Printed)

Address

City

State

ZIP Code

Odometer Disclosure Statement

I hereby certify that the odometer reading is the actual mileage of the vehicle unless one of the following statements is checked:

[ ] The mileage stated is in excess of its mechanical limits.
[ ] The odometer reading is not the actual mileage. WARNING – ODOMETER DISCREPANCY.

Transferor (Seller) Signature

Date

Transferee (Buyer) Signature

Date