Making a false statement or failing to accurately disclose the salvage status of a vehicle may subject
you to substantial civil fines in addition to any penalties under the Penal Law.
I certify that, to the best of my knowledge, this vehicle has been or has not been wrecked,
destroyed or damaged to such an extent that the total estimate, or actual cost, of parts and labor to
rebuild or reconstruct the vehicle to the condition it was in before an accident, and for legal operation
on the road or highways, is more than 75% of the retail value of the vehicle at the time of loss.
(Checking the “has
” box means that the vehicle must have an anti-theft examination before being
registered and that the title issued will have the statement “Rebuilt Salvage: NY” on it.)
o 1. I certify that, to the best of my knowledge, this odometer reading reflects the ACTUAL MILEAGE as
seen on the odometer of the vehicle described below.
2. I certify that, to the best of my knowledge, this odometer reading “EXCEEDS MECHANICAL LIMITS.”
(Odometer started over at zero)
3. I certify that, to the best of my knowledge, this odometer reading is “NOT THE ACTUAL MILEAGE.
WARNING - ODOMETER DISCREPANCY.”
o
o
ODOMETER AND DAMAGE DISCLOSURE STATEMENT
FEDERAL AND STATE LAWS REQUIRE THAT YOU PROVIDE THE MILEAGE AND CONDITION OF THE
VEHICLE DESCRIBED BELOW WHEN TRANSFERRING OWNERSHIP OF IT TO SOMEONE ELSE. IF YOU
DO NOT GIVE THE MILEAGE AND CONDITION INFORMATION TO THE NEW OWNER, OR IF YOU GIVE
FALSE MILEAGE INFORMATION, YOU MAY BE SUBJECT TO FINES AND/OR IMPRISONMENT.
(NO TENTHS)
MV-103 (7/16)
Skip the Trip! Do Your DMV Business On-Line At: dmv.ny.gov
Vehicle Year
Make
Model Body Type
Vehicle Identification Number
Seller’s Signature Seller’s Name (Print Name in Full)
Mailing Address (Include Street Number and Name, Rural Delivery, Box, Apt. No.)
Mailing Address (Include Street Number and Name, Rural Delivery, Box, Apt. No.)
City or Town State Zip Code Date of Statement
City or Town State Zip Code Date of Statement
X
X
New Owner’s Signature New Owner’s Name (Print Name in Full)
ODOMETER READING
The vehicle described below is equipped with an odometer that (please
check one):
o ______ has five digits, excluding tenths
o ______ has six digits, excluding tenths
Damage Disclosure Statement - Check One Box
Odometer Disclosure Statement
Enter odometer reading exactly as it appears on the
vehicle’s odometer (excluding tenths) and check applicable boxes.
Reset/clear
