Odometer Disclosure Statement For Title Transfers - Illinois Secretary Of State
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Secretary of State
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Secretary of State
Odometer isclosure Statement for Title Transfers
Secretary of State
Federal and state laws require that you state the mileage
Vehicle Services epartment
501 S. Second St., Rm. 055
in a transfer of ownership. Failure to complete or
providing a false statement may result in fines and/or
Springfield, IL 62756
imprisonment.
I, _________________________________________________ , certify to the best of my knowledge that the odometer
Seller’s name (type or print)
reading now reads ________________________ (no tenths) miles and reflects the actual mileage of the vehicle described
below, unless one of the following statements is checked:
The mileage stated is in excess of its mechanical limits.
The odometer reading is not the actual mileage. Warning odometer discrepancy.
Year _______________ Make _____________________ Body Type_________________ Model ____________________
Vehicle Identification Number __________________________________________________________________________
Seller’s Signature ____________________________________________________________________________________
Seller’s Printed Name_________________________________________________________________________________
Seller’s Address _____________________________________________________________________________________
Street
_________________________________________________________________________________________________________
City, State, ZIP
Seller’s Certification Date_____________________________________________________________________________
To be completed by the buyer
Buyer’s Signature____________________________________________________________________________________
Buyer’s Printed Name ________________________________________________________________________________
Buyer’s Address _____________________________________________________________________________________
Street
_________________________________________________________________________________________________
City, State, ZIP
Buyer’s Acknowledgment Date__________________________________________________________________________
Printed by authority of the State of Illinois. February 2016 — 1 — VSD 333.4
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