ODOMETER DISCLOSURE STATEMENT

Federal and State law requires that you state the mileage upon transfer of ownership. Failure to complete or provide a false statement may result in fines and/or imprisonment.

I, [SELLER’S NAME], state that the odometer now reads [#] miles (NO TENTHS) 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 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. WARNING – ODOMETER DISCREPANCY

VEHICLE DETAILS

• MAKE : [MAKE]
• BODY STYLE: [BODY STYLE]
• MODEL: [MODEL]
• YEAR: [YEAR]
• VEHICLE IDENTIFICATION NUMBER (VIN): [17 DIGITS]

LAST PLATE STATE: [STATE]

LAST PLATE NUMBER: [PLATE #]

SELLER’S SIGNATURE: ___________________________ DATE: __________
PRINT NAME: ___________________________
SELLER’S ADDRESS: _____________________________________

ACKNOWLEDGING MILEAGE READING AS CERTIFIED

BUYER’S SIGNATURE: ___________________________ DATE: __________
PRINT NAME: ___________________________
BUYER’S ADDRESS: _____________________________________
DATE OF CERTIFICATION: __________

The provisions of this disclosure statement section shall not apply to the following transfers:

1. A vehicle having a gross vehicle weight rating of more than 16,000 pounds;
2. A vehicle that is not self-propelled;
3. A vehicle that is 10 years old or older; or
4. A new vehicle prior to its first transfer for purposes other than resale.
5. A new vehicle sold directly by the manufacturer to any agency of the United States in conformity with contractual specifications.