Electronic Odometer Disclosure Statement

Vehicle Make:

Model:

Year:

Body Type:

Vehicle Identification Number (VIN):

Odometer Reading

Odometer Reading (no tenths):

Date of Statement:

I certify to the best of my knowledge that the odometer reading reflects the actual mileage of the vehicle described above, 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.

Seller Information

Name (Print):

Address:

Signature:

Date:

Buyer Information

Name (Print):

Address:

Signature:

Date: