Fillable Applicant'S Affidavit Odometer Reading Disclosure Statement Form printable pdf download

Applicant'S Affidavit Odometer Reading Disclosure Statement Form

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ERASURES & ALTERATIONS VOID THIS STATEMENT

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STATE OF OHIO

APPLICANT’S AFFIDAVIT

ODOMETER READING DISCLOSURE STATEMENT

(TYPE OR PRINT IN INK)

NOTICE TO APPLICANT FOR CERTIFICATE OF TITLE: 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

CHECK ONE OF THE FOLLOWING STATEMENTS. I (WE) CERTIFY THAT:

I (we) have made every effort possible and cannot locate the previous owner of the above

described motor vehicle to obtain the odometer statement required by Section 4505.06 of the

Revised Code.

I (we) obtained ownership of the above described motor vehicle by operation of law pursuant to

Section 4505.10; 4505.101; 4513.60; 4513.61 or 4513.62 of the Revised Code, and at the time

of transfer of ownership was not able to obtain a statement of the odometer reading from the

previous owner.

The above described motor vehicle (CHECK ONE) is

newly self-assembled,

is presently

evidenced by a salvage certificate of title, or

was previously registered/titled in another state,

province, or country and (CHECK ONE OF THE FOLLOWING):

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.

I (we) certify that the mileage registered on the odometer of this motor vehicle at the time of

_______________

application for title is

miles.

(Must be Completed)

______________________________

(APPLICANT’S SIGNATURE)

Sworn to before me and subscribed

___________

__________________________

________

In my presence the

day of

(Seal)

____________________________________

Clerk – Deputy Clerk – Notary Public

_____________________________

________.

My commission expires

APPLICANT’S AFFIDAVIT

Applicant'S Affidavit Odometer Reading Disclosure Statement Form

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