Odometer Disclosure Statement Template printable pdf download

Odometer Disclosure Statement Template

Odometer Disclosure Statement

Page 1 of 1

ODOMETER DISCLOSURE STATEMENT

Federal Regulations require you to state the mileage upon transfer of ownership of a motor

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

imprisonment.

I, _________________________________________ (Name of person making disclosure)

(Print)

hereby state that the odometer now reads _____________________ (no tenths) miles and

to the best of my knowledge it reflects the actual mileage of the vehicle described below,

unless one of the following statements is checked.

(1) I hereby certify that to the best of my knowledge the odometer reading reflects the

amount of mileage in excess of its mechanical limits.

(2) I hereby certify that the odometer reading is NOT the actual mileage.

WARNING-ODOMETER DISCREPANCY.

MAKE

MODEL

BODY TYPE

VEHICLE IDENTIFICATION NUMBER

YEAR

TRANSFEROR'S SIGNATURE (SELLER)

TRANSFEROR'S PRINTED NAME REQUIRED

TRANSFEROR'S STREET ADDRESS

CITY

STATE

ZIP

DATE OF DISCLOSURE STATEMENT

TRANSFEREE'S SIGNATURE (BUYER)

TRANSFEREE'S PRINTED NAME REQUIRED

TRANSFEREE'S STREET ADDRESS

CITY

STATE

ZIP

(Original-Title, Duplicate-Transferee, Triplicate-Transferor)

FST-306 (04/89)

Back to Clerk

mhtml:file://G:\Department\Docs\web site\Titles\Odometer Disclosure Statement.mht

10/12/2009

Odometer Disclosure Statement Template