Form T-107 - Odometer Discrepancy Affidavit - Seller(S)'/transferor(S)' Statement Of Facts
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1T-107 (Rev. 08-2005)
ODOMETER DISCREPANCY AFFIDAVIT
Seller(s)’/Transferor(s)’ Statement of Facts
This is to certify that on ____________________, I/we_________________________________________________________
(Date)
(Seller(s)’/Transferor(s)’ Full Legal Name(s)
__________________________________________________________________________________________________________________
(Seller(s)’/Transferor(s)’ Address)
sold or transferred the ownership of the following described vehicle: ________________
____________________________
(Year Model & Make)
(Vehicle Identification Number)
to: __________________________________________________________________________________________________
(Purchaser(s)’/Transferee(s)’ Full Legal Name(s) & Address)
* This is to certify that to the best of my knowledge that at the time that I sold or transferred the ownership of this vehicle, the
odometer mileage reading on this vehicle was ____________________ (No Tenths) and was the total actual mileage the
(Odometer Reading)
vehicle has traveled unless one of the following statements is checked:
1. The total actual mileage the vehicle has traveled exceeds the mechanical limits of the vehicle’s odometer, i.e. Mileage is
in excess of 99,999 on a five-digit odometer or 999,999 miles on a six-digit odometer.
2. The odometer reading does not
reflect the vehicle’s total actual mileage - Warning Odometer Discrepancy. In error, the documents pertaining to the transfer
of ownership of this vehicle reflects an incorrect odometer reading due to the following reason(s): * A reason for discrepancy
must be given or this form will not be accepted.
_____________________________________________________________________________________________________
Sworn to and subscribed before me this
_____________ day of ________________,
______
__________________________________________________
(Day)
(Month)
(Year)
(Seller(s)’ Signature(s)
___________________________________________________.
_________________________________________________________
(Notary Public’s Signature & Notary Seal/Stamp)
(Seller(s)’ Street Address)
____________________________________________________
_________________________________________________________
(Date My Notary Commission Expires)
(City, State and Zip)
_________________________________________________________
(Telephone No. Including Area Code)
Purchaser(s)’/Transferee(s)’ Statement of Facts
This is to certify that on _________________ , I/we____________________________________________________________
(Date)
(Purchaser(s)’/Transferee(s)’ Full Legal Name(s)
_____________________________________________________________________________________________________
(Purchaser(s)’/Transferee(s)’ Address Including City, State & Zip)
acquired the following described vehicle: __________________________________
________________________________
(Year Model & Make)
(Vehicle Identification Number)
from _________________________________________________________________________________________________
Seller(s)’/Transferor(s)’ Full Legal Name(s)
(
*This is to also certify to the best of my/our knowledge that at the time I/we acquired this vehicle, the odometer reading on this
vehicle was _______________ (No Tenths) and was the total actual mileage on the vehicle unless one of the following
(Odometer Reading)
statements is checked
1. The total actual miles the vehicle has traveled exceeds the mechanical limits of the vehicle’s odometer, i.e. Mileage is in
excess of 99,999 on a five-digit odometer or 999,999 miles on a six-digit odometer.
2. The odometer reading does not
reflect the total actual mileage - Warning Odometer Discrepancy. This is to certify that I/we am/are aware of the facts
contained in the above Statements of Facts from the seller(s)/transferor(s). I/we further agree to indemnify the Department of
Revenue for any and all losses that I/we might suffer due to the existence of facts to the contrary of those contained in this
affidavit:
Sworn to and subscribed before me this
__________day of ______________________, ________
__________________________________________________
(Day)
(Month)
(Year)
(Purchaser(s)’/Transferee(s)’ Signature(s)
_______________________________________
__________________________________________
(Notary Public’s Signature & Notary Seal/Stamp)
(Purchaser(s)’/Transferee(s)’ Street Address)
_______________________________________________
_______________________________
_________________
(Date My Notary Commission Expires)
(Purchaser(s)’ City State & Zip)
(Area Code & Phone#)
Important Notice: Affidavits should be obtained from all owners since this discrepancy in the odometer-reading recording
occurred. Also, persons appointed by power of attorney cannot complete this affidavit.
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