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Odometer Disclosure Statement

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ODOMETER DISCLOSURE STATEMENT

VSA 5 (07/25/2011)

Do not use this form if a title exists for this vehicle.

Purpose:

Use this form to comply with state and federal laws that require the seller of a motor vehicle to state the odometer mileage upon transfer

of ownership.

Instructions:

Print or Type - Failure to complete or providing false information may result in fines and/or imprisonment. (Sections 409, 412 and 413 of

the Motor Vehicle Information and Cost Savings Act of 1972, Section 46.2-629 of the Code of Virginia.)

VEHICLE INFORMATION

VEHICLE IDENTIFICATION NUMBER

MAKE

BODY TYPE

MODEL

YEAR

SELLER CERTIFICATION

Enter the odometer reading of the vehicle in the box to the right and check one of the following statements.

ODOMETER READING (no tenths)

CHECK ONE BOX ONLY:

Odometer reading entered is THE ACTUAL MILEAGE OF THE VEHICLE

Odometer reading entered is IN EXCESS OF ODOMETER'S MECHANICAL LIMITS

Odometer reading entered IS NOT THE ACTUAL MILEAGE. (WARNING-Odometer Discrepancy)

Vehicle model year is at least 10 years or older than the current calendar year and VEHICLE WAS EXEMPT FROM ODOMETER DISCLOSURE IN THE PRIOR STATE

OF TITLE (Applicant must present the out-of-state title showing the exemption)

I certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the

information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand

that knowingly making a false statement or representation on this form is a criminal violation.

SELLER NAME (print)

DATE (mm/dd/yyyy)

SELLER SIGNATURE

SELLER STREET ADDRESS

CITY

STATE

ZIP CODE

BUYER CERTIFICATION

By signing below I acknowledge and certify that I have received a copy of this completed form.

BUYER NAME (print)

BUYER SIGNATURE