VSA 5 (07/25/2011)
BUYER STREET ADDRESS CITY STATE ZIP CODE
ODOMETER DISCLOSURE STATEMENT
Do not use this form if a title exists for this vehicle.
Purpose: Use this form to comply with state and federal laws that require the seller of a motor vehicle to state the odometer mileage upon transfer
of ownership.
Instructions: Print or Type - Failure to complete or providing false information may result in fines and/or imprisonment. (Sections 409, 412 and 413 of
the Motor Vehicle Information and Cost Savings Act of 1972, Section 46.2-629 of the Code of Virginia.)
VEHICLE INFORMATION
MAKE BODY TYPE MODELVEHICLE IDENTIFICATION NUMBER YEAR
SELLER CERTIFICATION
BUYER CERTIFICATION
BUYER NAME (print) BUYER SIGNATURE
DATE (mm/dd/yyyy)
By signing below I acknowledge and certify that I have received a copy of this completed form.
I certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the
information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand
that knowingly making a false statement or representation on this form is a criminal violation.
Enter the odometer reading of the vehicle in the box to the right and check one of the following statements.
CHECK ONE BOX ONLY:
ODOMETER READING (no tenths)
Odometer reading entered is THE ACTUAL MILEAGE OF THE VEHICLE
Odometer reading entered is IN EXCESS OF ODOMETER'S MECHANICAL LIMITS
Odometer reading entered IS NOT THE ACTUAL MILEAGE. (WARNING-Odometer Discrepancy)
Vehicle model year is at least 10 years or older than the current calendar year and VEHICLE WAS EXEMPT FROM ODOMETER DISCLOSURE IN THE PRIOR STATE
OF TITLE (Applicant must present the out-of-state title showing the exemption)
SELLER NAME (print)
SELLER STREET ADDRESS CITY STATE ZIP CODE
SELLER SIGNATURE
DATE (mm/dd/yyyy)
