Odometer Disclosure Statement (Page 2 of 3) in pdf

Odometer Disclosure Statement Page 2

TENNESSEE DEPARTMENT OF REVENUE

ODOMETER DISCLOSURE STATEMENT

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.

SELLER OR TRANSFEROR’S NAME (PLEASE PRINT)

certify to the best of my knowledge that the odometer reading on the vehicle described below is the actual mileage of the

vehicle unless one of the following statements is checked:

ODOMETER READING (NO TENTHS)

I hereby certify that the mileage stated is in excess of the mechanical limits of the odometer.

The odometer reading is not the actual mileage. WARNING - ODOMETER DISCREPANCY.

MAKE

MODEL

BODY TYPE

VEHICLE IDENTIFICATION NUMBER

YEAR

CITY

SELLER OR TRANSFEROR’S ADDRESS

STATE

ZIP CODE

SELLER OR TRANSFEROR’S SIGNATURE

DATE OF THIS STATEMENT

BUYER OR TRANSFEREE’S NAME (PLEASE PRINT)

BUYER OR TRANSFEREE’S ADDRESS

CITY

STATE

ZIP CODE

BUYER OR TRANSFEREE’S SIGNATURE

RV-F1317001 (Rev. 4-05)

RDA-692

OWNER

Odometer Disclosure Statement Page 2