Odometer Disclosure Statement

Federal and State law require that you state the mileage upon transfer of ownership. Failure to complete or providing a false statement may result in fines and/or imprisonment.

Vehicle Information

Year

Make

Model

Vehicle Identification Number (VIN)

Odometer Reading

Current Mileage (no tenths)

The mileage stated is in excess of its mechanical limits.

The odometer reading is not the actual mileage. WARNING – ODOMETER DISCREPANCY.

Seller Information and Certification

Seller's Printed Name

Seller's Signature

Date

Seller's Address

Buyer Information

Buyer's Printed Name

Buyer's Signature

Date

Buyer's Address