Form Tc-896 -Odometer Disclosure Statement Leased Vehicle printable pdf download

Form Tc-896 -Odometer Disclosure Statement Leased Vehicle

TC-896

ODOMETER DISCLOSURE STATEMENT

Rev. 6/89

TC-896.CDR

LEASED VEHICLE

Federal and Utah State law require that the lessee disclose the mileage to the lessor in

connection with the transfer of ownership. Failure to complete or providing a false

statement may result in fines and/or imprisonment. Complete the disclosure below and

return to lessor.

Year

Make

Model

Body Type

Vehicle Identification Number

(print name of person making disclosure) state that the odometer now reads:

(NO TENTHS)

ODOMETER READING

miles and to the best of my knowledge that it reflects the actual mileage of the vehicle

described above, unless one of the following statements is checked.

(1) I hereby certify that to the best of my knowledge the odometer reading

reflects the amount of mileage in excess of its mechanical limits.

(2) I hereby certify that the odometer reading is NOT the actual mileage.

Lessee's Name (Print)

Authorized Agent (Print)

Lessee's Signature

Lessee's Address

City

State

ZIP

Date of Statement

Authorized Agent (Print)

Lessor's Name (Print)

Lessor's Signature

City

State

ZIP

Lessor's Address

Date Completed Disclosure Received from Lessee

Date Disclosure Sent to Lessee

Form Tc-896 -Odometer Disclosure Statement Leased Vehicle