Odometer Disclosure Statement Template

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Odometer Disclosure Statement
Page 1 of 1
ODOMETER DISCLOSURE STATEMENT
Federal Regulations require you to state the mileage upon transfer of ownership of a motor
vehicle. Failure to complete or providing a false statement may result in fines and/or
imprisonment.
I, _________________________________________ (Name of person making disclosure)
(Print)
hereby state that the odometer now reads _____________________ (no tenths) miles and
to the best of my knowledge it reflects the actual mileage of the vehicle described below,
unless one of the following statements is checked.
g
f
e
d
c
(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.
g
f
e
d
c
(2) I hereby certify that the odometer reading is NOT the actual mileage.
WARNING-ODOMETER DISCREPANCY.
MAKE
MODEL
BODY TYPE
-
VEHICLE IDENTIFICATION NUMBER
YEAR
-
TRANSFEROR'S SIGNATURE (SELLER)
TRANSFEROR'S PRINTED NAME REQUIRED
TRANSFEROR'S STREET ADDRESS
CITY
STATE
ZIP
DATE OF DISCLOSURE STATEMENT
TRANSFEREE'S SIGNATURE (BUYER)
TRANSFEREE'S PRINTED NAME REQUIRED
TRANSFEREE'S STREET ADDRESS
CITY
STATE
ZIP
(Original-Title, Duplicate-Transferee, Triplicate-Transferor)
FST-306 (04/89)
Back to Clerk
mhtml:file://G:\Department\Docs\web site\Titles\Odometer Disclosure Statement.mht
10/12/2009

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