Odometer Disclosure Statement Odometer Disclosure
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1ODOMETER DISCLOSURE STATEMENT
ODOMETER DISCLOSURE STATEMENT
State Form 43230 (R / 2-97)
State Form 43230 (R / 2-97)
STATE OF INDIANA
STATE OF INDIANA
BUREAU OF MOTOR VEHICLES
BUREAU OF MOTOR VEHICLES
We, the undersigned, swear of affirm that the information entered on this form is correct. We
We, the undersigned, swear of affirm that the information entered on this form is correct. We
understand that a false statement may constitute the crime of perjury.
understand that a false statement may constitute the crime of perjury.
Federal and State law requires that you state the mileage upon transfer of ownership. Failure
Federal and State law requires that you state the mileage upon transfer of ownership. Failure
to complete or providing a false statement may result in fines, imprisonment, or both.
to complete or providing a false statement may result in fines, imprisonment, or both.
I, __________________________________ residing at ______________________________
I, __________________________________ residing at ______________________________
PRINTED NAME OF SELLER(S)
PRINTED NAME OF SELLER(S)
_____________________________________________ certify to the best of my knowledge
_____________________________________________ certify to the best of my knowledge
ADDRESS OF SELLER
ADDRESS OF SELLER
that the odometer reading is the actual mileage of the vehicle described below unless one of the
that the odometer reading is the actual mileage of the vehicle described below unless one of the
following statements is checked:
following statements is checked:
1. I hereby certify that to the best of my knowledge the odometer reading
1. I hereby certify that to the best of my knowledge the odometer reading
Miles (no tenths)
Miles (no tenths)
reflects the amount of mileage in excess of its mechanical limits.
reflects the amount of mileage in excess of its mechanical limits.
2. I hereby certify that the odometer reading is NOT the actual mileage.
2. I hereby certify that the odometer reading is NOT the actual mileage.
WARNING - ODOMETER DISCREPANCY.
WARNING - ODOMETER DISCREPANCY.
Vehicle year
Vehicle year
Vehicle make
Vehicle make
Vehicle identification number (VIN)
Vehicle identification number (VIN)
I will not hold the Commissioner of the Bureau of Motor Vehicles, employees of the Bureau of
I will not hold the Commissioner of the Bureau of Motor Vehicles, employees of the Bureau of
Motor Vehicles, License Branches or their employees in the State of Indiana responsible for any
Motor Vehicles, License Branches or their employees in the State of Indiana responsible for any
discrepancy shown on the odometer reading.
discrepancy shown on the odometer reading.
Signature of seller(s)
Signature of seller(s)
Date
Date
PURCHASER'S INFORMATION
PURCHASER'S INFORMATION
I am aware of the above odometer certification made by the seller(s).
I am aware of the above odometer certification made by the seller(s).
Name of purchaser(s)
Signature of purchaser(s)
Name of purchaser(s)
Signature of purchaser(s)
Address of purchaser
Address of purchaser
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