Secretary of State
Odometer Disclosure Statement for Title Transfers
Secretary of State
Vehicle Services Department
501 S. Second St., Rm. 055
Springfield, IL 62756
www.cyberdriveillinois.com
Federal and state laws require that you state the mileage
in a transfer of ownership. Failure to complete or
providing a false statement may result in fines and/or
imprisonment.
This space for use by
Secretary of State
I, _________________________________________________ , certify to the best of my knowledge that the odometer
reading now reads ________________________ (no tenths) miles and reflects the actual mileage of the vehicle described
below, unless one of the following statements is checked:
❏ The mileage stated is in excess of its mechanical limits.
❏ The odometer reading is not the actual mileage. Warning odometer discrepancy.
Year
_______________
Make
_____________________
Body Type_________________ Model ____________________
Vehicle Identification Number __________________________________________________________________________
Seller’s Signature ____________________________________________________________________________________
Seller’s Printed Name_________________________________________________________________________________
Seller’s Address _____________________________________________________________________________________
_________________________________________________________________________________________________________
Seller’s Certification Date_____________________________________________________________________________
To be completed by the buyer
Buyer’s Signature____________________________________________________________________________________
Buyer’s Printed Name ________________________________________________________________________________
Buyer’s Address _____________________________________________________________________________________
_________________________________________________________________________________________________
Buyer’s Acknowledgment Date__________________________________________________________________________
Printed by authority of the State of Illinois. February 2016 — 1 — VSD 333.4
Street
City, State, ZIP
Seller’s name (type or print)
Street
City, State, ZIP
Secretary of State
Odometer Disclosure Statement for Title Transfers
Secretary of State
Vehicle Services Department
5
01 S. Second St., Rm. 055
Springfield, IL 62756
www.cyberdriveillinois.com
Federal and state laws require that you state the mileage
i
n a transfer of ownership. Failure to complete or
providing a false statement may result in fines and/or
imprisonment.
T
his space for use by
Secretary of State
I, _________________________________________________ , certify to the best of my knowledge that the odometer
reading now reads ________________________ (no tenths) miles and reflects the actual mileage of the vehicle described
below, unless one of the following statements is checked:
❏ The mileage stated is in excess of its mechanical limits.
❏ The odometer reading is not the actual mileage. Warning odometer discrepancy.
Year
_______________
Make
_____________________
Body Type_________________ Model ____________________
Vehicle Identification Number __________________________________________________________________________
Seller’s Signature ____________________________________________________________________________________
Seller’s Printed Name_________________________________________________________________________________
Seller’s Address _____________________________________________________________________________________
_________________________________________________________________________________________________________
Seller’s Certification Date_____________________________________________________________________________
To be completed by the buyer
Buyer’s Signature____________________________________________________________________________________
Buyer’s Printed Name ________________________________________________________________________________
Buyer’s Address _____________________________________________________________________________________
_________________________________________________________________________________________________
Buyer’s Acknowledgment Date__________________________________________________________________________
Printed by authority of the State of Illinois. February 2016 — 1 — VSD 333.4
Street
City, State, ZIP
Seller’s name (type or print)
Street
City, State, ZIP
