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Cuyahoga County Clerk of Courts
Cuyahoga County Fiscal Officer
GERALD E. FUERST
ERASURES & ALTERATIONS VOID THIS STATEMENT
STATE OF OHIO
APPLICANT'S AFFIDAVIT
ODOMETER READING DISCLOSURE STATEMENT
(TYPE OR PRINT IN INK)
This form available electronically at our website
NOTICE TO APPLICANT FOR CERTIFICATE OF TITLE: YOU ARE REQUIRED BY LAW TOENTER ALL
INFORMATION REQUIRED HEREIN, INCLUDING THE ODOMETER READINGOF THIS MOTOR
VEHICLE IN THE AFFIDAVIT IMMEDIATELY FOLLOWING. THE MAKINGOF A FALSE STATEMENT
UNDER OATH OR AFFIRMATION IS IN VIOLATION OF SECTION2921.13 OF THE REVISED CODE AND
IS PUNISHABLE BY SIX MONTHS IMPRISONMENTAND A FINE OF UP TO ONE THOUSAND DOLLARS,
OR BOTH.
STATE OF OHIO, ________________________ COUNTY DATE ___________________________
YEAR___________ MFR'S SERIAL NO.____________________________ MAKE_________________
MODEL _________________________ BODY TYPE _________________ MOTOR NO. ___________
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 Sections
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
is
newly self assembled,
is presently evidenced
(CHECK ONE)
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
SEAL Sworn to and subscribed in my presence by ___________________________________ this
_____ day of _____________ 20___.
Commission expirers ____________________ 20 ___.
SEAL
___________________________________________________
(CLERK, DEPUTY CLERK OF COURTS – NOTARY)
APPLICANT’S AFFIDAVIT
COC-ATMV-04 (Rev. 04-07)
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