Odometer Disclosure Statement
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1ODOMETER DISCLOSURE STATEMENT
Form 78-015-10-1-1-000
BOTH FEDERAL LAW AND STATE LAW REQUIRE THAT YOU (THE TRANSFEROR) 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,
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 MIELAGE OF THE VEHICLE IN EXCESS OF THE ODOMETER'S MECHANICAL
LIMITS.
(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
PRINTED NAME
TRANSFEROR'S ADDRESS
STREET
CITY OR TOWN
STATE
ZIP CODE
DATE OF STATEMENT
TRANSFEREE'S SIGNATURE
PRINTED NAME
TRANSFEREE'S NAME
- ENTER NAME AS IT APPEARS ON THE ASSIGNMENT OF MGFR'S. CERTIFICATE OF ORIGIN,OR TITLE
TRANSFEREE'S ADDRESS
STREET
CITY OR TOWN
STATE
ZIP CODE
Title Bureau,
P. O. Box 1383,
Jackson, MS 39215
Phone 601-923-7200
Fax 601-923-7224
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