Form Tc-891 - Odometer Disclosure Statement - 2010
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Division of Motor Vehicles
Odometer Disclosure Statement
UTAH STATE TAX COMMISSION
PO Box 30412, Salt Lake City, UT 84130
Telephone (801) 297-7780 or 1-800-DMV-UTAH
Get forms online - tax.utah.gov
Section 1 - Transferor Information
Transferor’s name (print last, first, middle initial, or business name)
City
State
Zip code
Street address
Section 2 - Vehicle Information
Year
Make
Model
Vehicle/Hull Identification Number (VIN/HIN)
Body type
Section 3 - Odometer Disclosure
Federal and State law require that you furnish to the transferee a written odometer disclosure statement upon transfer of ownership.
Failure to complete or providing a false statement may result in fines and/or imprisonment. Both the transferor and the transferee shall
retain a legible copy of the odometer disclosure statement for not less than four years.
I certify that the odometer reading: (check one)
Reflects the actual mileage.
Reflects the mileage in excess of the odometer’s mechanical limits.
Enter odometer reading (no tenths)
Is not the actual mileage. Warning - Odometer Discrepancy
Transferor’s signature
Date of statement
X
Section 4 - Transferee Information
Transferee’s name (print last, first, middle initial, or business name)
Street address
City
State
Zip code
Transferee’s signature
Date of statement
X
TC-891 Rev. 9/10
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Parent category: Financial