Vehicle Bill Of Sale Template Page 2
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2ODOMETER DISCLOSURE STATEMENT
Federal and State law require that you state the odometer mileage upon transfer of ownership. Failure to
complete or providing a false statement may result in fines and/or imprisonment.
************ TO BE COMPLETED BY THE SELLER ************
I/We ___________________________ state that the odometer mileage indicated for the vehicle described
below is:
______________________ (check one) ___ Miles ___ Kilometers ___ Hours
and I hereby certify to the best of my knowledge that (check one statement below that is applicable)
____ (1) The odometer reading is the actual mileage.
____ (2) The odometer reading reflects the amount of mileage in excess of its mechanical limits.
____ (3) The odometer reading is not actual mileage. WARNING – ODOMETER DISCREPANCY.
YEAR
MAKE
BODY TYPE
MODEL
Vehicle Identification Number: ___________________
Printed Name of Seller: ___________________________
Address of Seller: ___________________________________________
Seller’s Signature:____________________
Seller’s Certification Date:___________________
************ TO BE COMPLETED BY THE BUYER ************
Printed Name of Buyer:_________________________
Address of Buyer: _____________________________
_____________________________
Buyer’s Signature: _____________________________
Date Completed Form Received: _____________________________
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