Odometer Disclosure Statement Template - Ky
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1TRANSPORTATION CABINET
TC 96-5
Division of Motor Vehicle Licensing
2 / 08
P.O. Box 2014
Frankfort, KY 40622
Odometer Disclosure Statement
Federal Law requires that you state the mileage upon transfer of ownership. Failure to complete or providing a false
statement may result in fines and/or imprisonment. KY odometer law KRS 190.300
I,
, state that the odometer now reads
miles and, to the
_________________________________________________
_________________
(Transferor’s name, Print)
(No Tenths)
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)
________________________________________________
(Printed Name)
Transferor’s Address
___________________________________________________________________________________________________
(Street)
_________________________________________________________________________________________________________________________
(City)
(State)
(Zip Code)
Date of Statement _________________________________________________
__________________________________________________
(Transferee’s Signature)
__________________________________________________
(Printed Name)
Transferee’s Name
_____________________________________________________________________________________________________
Transferee’s Address
___________________________________________________________________________________________________
(Street)
_________________________________________________________________________________________________________________________
(City)
(State)
(Zip Code)
Subscribed and sworn before me this _______________ day of ____________________ 20______________
My commission expires _____________________________________________________________________
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