ODOMETER DISCLOSURE STATEMENT
Federal and State law require that you state the mileage upon transfer of ownership.
Failure to complete or providing a false statement may result in fines and/or
imprisonment.
I, ______________________ (SELLER’S NAME, PRINT) 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
MAKE ______________ BODY STYLE ______________ YEAR ______________
MODEL ______________ VIN ______________________________________
LAST PLATE STATE ______________ LAST PLATE NUMBER ______________
SELLER’S SIGNATURE _________________ SELLER’S NAME _________________
SELLER’S ADDRESS ___________________________________________________
CITY _________________ STATE _________________ ZIP CODE _______________
ACKNOWLEDGING MILEAGE READING AS CERTIFIED
BUYER’S SIGNATURE _________________ BUYER’S NAME _________________
BUYER’S ADDRESS ___________________________________________________
CITY _________________ STATE _________________ ZIP CODE _______________
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.
