Odometer Disclosure Statement Form printable pdf download

Odometer Disclosure Statement Form

Odometer Disclosure Statement

Federal and State law require that you state the odometer mileage upon transfer of ownership.

Failure to complete or providing a false statement may result in fines and/or imprisonment.

TO BE COMPLETED BY THE SELLER

I/We _____________________________________ state that the odometer mileage indicated for the

Vehicle described below is: ___________________ (check one)

Miles

Kilometers

Hours.

And I/We hereby certify to the best of my/our knowledge that (check one statement below that is

applicable)

(1) the odometer reading is the actual mileage.

(2) the odometer reading reflects the amount of mileage in excess of its mechanical limits.

(3) the odometer reading is not actual mileage. Warning – Odometer discrepancy.

Year of Manufacture

Make

Body Type

Model

Vehicle Identification Number

Printed Name of Seller:

Address of Seller:

Seller’s Signature:

Seller’s Certification Date:

TO BE COMPLETED BY THE BUYER

Printed Name of Transferee (Buyer):

Address of Buyer:

Buyer’s Signature:

Date Completed Form Received:

Odometer Disclosure Statement Form