Please complete, sign and submit the form
by Fax: 1-877-501-7620
Or mail: Chase Auto
PO Box 901069
Fort Worth, TX 76101-2069
ODOMETER DISCLOSURE STATEMENT (LEASED VEHICLES)
Lessee’s Name and Address Information:HICLE
Federal law (and State law, if applicable) requires that the lessee disclose the mileage to the lessor in connection with the
transfer of ownership. Failure to complete or making a false statement may result in fines and/or imprisonment.
When returning or purchasing your leased vehicle, please complete, sign and return disclosure form below to
JPMorgan Chase Bank, N.A.
I ________________________________________ (print name of person making disclosure),
state that the odometer now reads _____________ (no tenths) miles.
I further state the following (please place a checkmark next to only one of the following statements):
I certify that, to the best of my knowledge, the above-listed odometer reading reflects the amount of mileage IN EXCESS OF ITS
MECHANICAL LIMITS.
I certify that, to the best of my knowledge, the above-listed odometer reading reflects the ACTUAL MILEAGE of the vehicle described below.
CITY �
STATE ZIP
Lessor’s Name: __________________________________________________________________________________________________________
I certify that the above-listed odometer reading is NOT the actual mileage.
CALIFORNIA LESSEES: I certify, under penalty of perjury under the laws of the State of California, the foregoing odometer information is
true and correct.
Lessee Name:
Lessee Address:
Lessee’s Signature: _______________________________________________________________
Date of Statement: _______________________________________________________________
The Odometer Disclosure Statement cannot be altered in any way. Please do not strike through any information, use white-out, or check
any incorrect boxes. If any information needs to be corrected, please use a new form.
DO NOT WRITE BELOW THIS LINE
Date Disclosure Form sent to Lessee: _________________________________________________________________________________________
Date Completed Disclosure Form Received from Lessee: _________________________________________________________________________
Lessor’s Signature: _______________________________________________________________________________________________________
Name and Title: ______________________________________________________________________________________________
Version 2.B
(19-104-F) 3/20
Year
Make
Model
Vehicle Identification Number (VIN)
Body Type (select one):
Convertible Coupe Sedan SUV
Other
Truck
JPMorgan Chase Bank, N.A.
/HVVRU¶V $GGUHVV
Chase Auto, 14800 Frye Rd, Mail Code TX1-0055, Ft. Worth, TX 76155
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