Odometer Disclosure Statement printable pdf download

Odometer Disclosure Statement

VEHICLE DESCRIPTION

Year:________________

Make:____________________

Model:_________________________

Vehicle Identification Number:_________________________________________________________

ODOMETER DISCLOSURE STATEMENT

WARNING: Federal and State Law requires that you state the mileage in connection with the transfer

of ownership. Failure to complete or providing a false statement may result in fines and/or

imprisonment.

I, _____________________________________________, the seller, certify to the best of my knowledge

that the odometer reading on the vehicle described above is the mileage of the vehicle according the

following checked boxes:

We state that this

or 6 digit odometer now reads

.XX (no tenths)

miles, DATE READ ______/______/______, and we hereby certify that to the best of knowledge the odometer

reading:

REFLECTS ACTUAL MILEAGE.

IS IN EXCESS OF ITS MECHANICAL LIMITS. (Applies only to 5 digit odometers)

IS NOT THE ACTUAL MILEAGE. WARNING – ODOMETER DISCREPENCY

UNDER PENALTIES OF PERJURY, I HEREBY DECLARE THAT I HAVE READ THE FOREGOING

DOCUMENT AND THE FACTS STATED WITHIN IT ARE TRUE.

________________________________________________________________________________________

Seller's Signature

Seller's Printed Name

_________________________________________________________________________________________

Seller's Street Address

City/State/Zip

________________________________________________________________________________________

Buyer's Signature

Buyer's Printed Name

_________________________________________________________________________________________

Buyer's Street Address

City/State/Zip

Odometer Disclosure Statement