Odometer Mileage Disclosure Statement Template

If you are purchasing* your vehicle:

If you are returning your vehicle:

A. Print form

Please complete and fax to: 972-590-3968

B. Bring along to vehicle turn-in

OR

C. Complete and sign at dealer

Attach form to check and send to:

HCA Exchange, Inc.

Dept. CH 14301

Palatine, IL 60055-4301

Odometer/Mileage Disclosure Statement

Complete the information below

Federal law (and State law, if applicable) requires that the lessee disclose the mileage to the lessor in connection with the transfer of

ownership. Failure to complete or making a false statement may result in fines and/or imprisonment. Complete disclosure form below

and return to lessor.

I, ___________________ (name of person making disclosure, Print) state that the odometer now reads ________ (no tenths)

miles and to the best of my knowledge that it reflects the actual mileage of the vehicle described below, 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.

Make

Model

Body Type

VIN (

Vehicle Information Number)

Year

Lessee’s Name(s)

Lessee’s Address

Lessee’s Signature(s)

Date of Statement

DO NOT WRITE BELOW THIS LINE

Lessor’s Name

Lessor’s Address

Date Disclosure Form sent to Lessee

Date Completed Disclosure Form Received from Lessee

Lease Account Number

Lessor’s Signature

Name & Title

Notice is hereby given that the rights, but not the obligations, of Hyundai Lease Titling Trust (“HLTT”) under the sale agreement for the asset described in this agreement have

been assigned to HCA Exchange, Inc. pursuant to an agreement between HLTT and HCA Exchange, Inc.

* If state allows direct purchase.