Form 3019 - Odometer Disclosure Statement
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MISSOURI DEPARTMENT OF REVENUE
Federal law (and State law, if
FORM
MOTOR VEHICLE BUREAU
applicable) requires that you state
ODOMETER DISCLOSURE
3019
the mileage upon transfer of
ownership. Failing to complete or
STATEMENT
providing a false statement may
(REV. 11-2005)
INSTRUCTIONS ON REVERSE
result in fines and/or imprisonment.
YEAR
MAKE
VEHICLE IDENTIFICATION NUMBER
TITLE NUMBER
STATE
MODEL
BODY STYLE
If purchaser/seller is an agent/officer of a firm, record official position after printed name. The purchaser/seller should
retain a copy of this odometer disclosure statement. If “Warning, Odometer Discrepancy” is checked, the seller must
attach a statement explaining all facts regarding the discrepancy.
PURCHASER(S) NAME
DATE
(PRINTED OR TYPED)
ADDRESS
SELLER(S) (FIRM) NAME
DEALER NO.
(PRINTED OR TYPED)
ADDRESS
ODOMETER READING
I state that the odometer now reads the aforementioned miles and to the
Mileage in excess of its mechanical limits
(NO TENTHS)
best of my knowledge that it reflects the actual mileage of the vehicle
Mileage reading not actual
described herein, unless one of the following statements is checked.
(WARNING, ODOMETER DISCREPANCY)
SIGNATURE OF PURCHASER(S)
SIGNATURE OF SELLER(S)
HAND PRINTED NAME(S) BY PURCHASER(S)
HAND PRINTED NAME(S) BY SELLER(S)
PURCHASER(S) NAME
DATE
(PRINTED OR TYPED)
ADDRESS
SELLER(S) (FIRM) NAME
DEALER NO.
(PRINTED OR TYPED)
ADDRESS
ODOMETER READING
I state that the odometer now reads the aforementioned miles and to the
Mileage in excess of its mechanical limits
(NO TENTHS)
best of my knowledge that it reflects the actual mileage of the vehicle
Mileage reading not actual
described herein, unless one of the following statements is checked.
(WARNING, ODOMETER DISCREPANCY)
SIGNATURE OF PURCHASER(S)
SIGNATURE OF SELLER(S)
HAND PRINTED NAME(S) BY PURCHASER(S)
HAND PRINTED NAME(S) BY SELLER(S)
PURCHASER(S) NAME
DATE
(PRINTED OR TYPED)
ADDRESS
SELLER(S) (FIRM) NAME
DEALER NO.
(PRINTED OR TYPED)
ADDRESS
ODOMETER READING
I state that the odometer now reads the aforementioned miles and to the
Mileage in excess of its mechanical limits
(NO TENTHS)
best of my knowledge that it reflects the actual mileage of the vehicle
Mileage reading not actual
described herein, unless one of the following statements is checked.
(WARNING, ODOMETER DISCREPANCY)
SIGNATURE OF PURCHASER(S)
SIGNATURE OF SELLER(S)
HAND PRINTED NAME(S) BY PURCHASER(S)
HAND PRINTED NAME(S) BY SELLER(S)
PURCHASER(S) NAME
DATE
(PRINTED OR TYPED)
ADDRESS
SELLER(S) (FIRM) NAME
DEALER NO.
(PRINTED OR TYPED)
ADDRESS
ODOMETER READING
I state that the odometer now reads the aforementioned miles and to the
Mileage in excess of its mechanical limits
(NO TENTHS)
best of my knowledge that it reflects the actual mileage of the vehicle
Mileage reading not actual
described herein, unless one of the following statements is checked.
(WARNING, ODOMETER DISCREPANCY)
SIGNATURE OF PURCHASER(S)
SIGNATURE OF SELLER(S)
HAND PRINTED NAME(S) BY PURCHASER(S)
HAND PRINTED NAME(S) BY SELLER(S)
MO 860-2086 (11-2005)
DISTRIBUTION: WHITE—ATTACH TO MSO OR CERT. OF TITLE
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