Seller'S Affidavit Odometer Reading Disclosure Statement Form
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DO NOT DETACH FROM TITLE
ERASURES & ALTERATIONS VOID THIS STATEMENT
STATE OF OHIO
SELLER’S AFFIDAVIT
ODOMETER READING DISCLOSURE STATEMENT
(TYPE OR PRINT IN INK)
NOTICE TO TRANSFEROR: YOU ARE REQUIRED BY LAW TO ENTER ALL INFORMATION
REQUIRED HEREIN, INCLUDING THE ODOMETER READING OF THE MOTOR VEHICLE IN
THE AFFIDAVIT IMMEDIATELY FOLLOWING. THE MAKING OF A FALSE STATEMENT UNDER
OATH OR AFFIRMATION IS IN VIOLATION OF SECTION 2921.13 OF THE REVISED CODE
AND IS PUNISHABLE BY SIX MONTHS IMPRISONMENT AND A FINE OF UP TO ONE
THOUSAND DOLLARS, OR BOTH.
___________________
_______________
STATE OF OHIO,
COUNTY SS:
DATE
______________________
________________________
YEAR
MFR’S SERIAL NO.
_______________________
_______________________________
MAKE
MODEL
___________________
BODY TYPE
_________________________________________________
PURCHASER’S NAME
I (we) certify that the mileage registered on this vehicle at the time of assignment is
___________
miles.
CHECK ONE OF THE FOLLOWING STATEMENTS. I (WE) CERTIFY THAT:
To the best of my (our) knowledge, the Odometer reading reflects the actual mileage;
The odometer reading reflects mileage in excess of the designed mechanical limit of 99,999
miles;
To the best of my (our) knowledge, the Odometer reading is not the actual mileage and should
not be relied upon.
CHECK ONE OF THE FOLLOWING. I (WE) CERTIFY THAT WHILE IN MY (OUR) POSSESSION:
The Odometer of this vehicle was not altered, set back, or disconnected;
The Odometer of this vehicle was repaired or replaced.
______________________________
(TRANSFEROR’S SIGNATURE)
Sworn to before me and subscribed
___________
__________________________
________
In my presence the
day of
20
(Seal)
____________________________________
Clerk – Deputy Clerk – Notary Public
_____________________________
________.
My commission expires
20
SELLER’S AFFIDAVIT
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