Out-of-State Vehicle Odometer Disclosure Statement

Seller’s Name Seller’s Address

Buyer’s Name Buyer’s Address

Vehicle Information

Make Model Year Vehicle Identification Number (VIN) Odometer Reading (no tenths) Odometer Status

I certify that to the best of my knowledge the odometer reading is correct and reflects the actual mileage of the vehicle unless one of the following statements is checked.

Seller’s Signature Date

Buyer’s Signature Date