Fillable LEASED VEHICLE RETURN RECEIPT and ODOMETER DISCLOSURE STATEMENT (Honda Financial Services)

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LEASED VEHICLE RETURN RECEIPT and ODOMETER DISCLOSURE STATEMENT (Honda Financial Services)

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LEASED VEHICLE RETURN RECEIPT and ODOMETER DISCLOSURE STATEMENT
This Leased Vehicle Return Receipt and Odometer Disclosure Statement (Receipt) acknowledges that the leased
vehicle described below has been returned to the dealership referenced below. This Receipt DOES NOT establish
the accurate condition of the vehicle, amount required to complete repairs, any further lease termination liability that
may be owed by the lessee and any release from terms and conditions of the original lease agreement.
LESSEE INFORMATION
Lease Account Number
Name & Address
DEALER INFORMATION
Dealer Number
Dealer Name & Address
VEHICLE INFORMATION
Year
Make
Model
VIN
Odometer Reading
Vehicle Return Date
Vehicle condition about the same as the Vehicle Inspection Report
Vehicle condition improved with the following repairs:
Vehicle condition changed due to the following additional damage (since the Vehicle Inspection report):
Vehicle inspection was not performed. Vehicle condition pending final inspection by AHFC.
ODOMETER DISCLOSURE STATEMENT
Federal Law and State Laws require that Lessee state the mileage upon transfer of ownership. Failure to complete or
making a false statement may result in fines and/or imprisonment. Lessee named above states that the odometer now
reads (no tenths) miles and Lessee hereby certifies that to the best of their knowledge: (check one)
(1) The odometer reading reflects the actual mileage of the vehicle described above.
(2) The odometer reading reflects the amount of mileage in excess of its mechanical limits.
(3) The odometer reading is not the actual mileage. WARNING - ODOMETER DISCREPANCY.
ACKNOWLEDGMENTS
Lessee (Print Name and Sign)
Date
Date Form
Sent to Lessee
Date Completed Form
Received from Lessee
Dealer Representative (Print Name and Sign)
Date
CUSTOMER:
Please retain a copy for your records. For further assistance, please contact (800) 708-6555.
DEALER:
Please update return information on VIPS website. Vehicles must be confirmed on VIPS.
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LEASED VEHICLE RETURN RECEIPT and ODOMETER DISCLOSURE STATEMENT (Honda Financial Services)

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Completed 15 January 2021

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