TENNESSEE DEPARTMENT OF REVENUE
TAXPAYER AND VEHICLE SERVICES DIVISION
VEHICLE SERVICES SECTION
This is to certify that on
ODOMETER DISCREPANCY
CERTIFICATION
,
DATE SELLER'S NAME
SELLER'S ADDRESS
sold the following described vehicle:
YEAR-MODEL-MAKE
VEHICLE & VEHICLE IDENTIFICATION NUMBER
to
PURCHASER'S NAME & ADDRESS
This is to also certify that at the time that I sold/transferred this vehicle, the odometer reading on this vehicle was:
and to the best of my knowledge reflected the correct odometer reading. In error, the documents pertaining to the transfer of
ownership of this vehicle reflected an incorrect odometer reading due to the following reason(s):
Under Federal Law, making an inaccurate or untruthful statement may make you liable for civil damages and for civil or criminal
penalties, pursuant to the Motor Vehicle Information and Cost Savings Act of 1972 (Pub. L. 92-513 as amended by Pub. L. 99-
579).
Under penalties of perjury, I hereby certify this information is correct to the best of my knowledge.
SIGNATURE OF CERTIFIER/SELLER
SELLER MUST HAND PRINT NAME
TELEPHONE NUMBER & AREA CODE
DATE
SELLER'S STREET ADDRESS
CITY & STATE
PURCHASER'S STATEMENT OF FACTS:
This is to certify that on
DATE
, I,
PURCHASER'S NAME
PURCHASER'S ADDRESS
purchased the following described vehicle:
YEAR-MODEL-MAKE
VEHICLE IDENTIFICATION NUMBER
from
SELLER'S NAME & ADDRESS
This is to also certify that at the time that I acquired this vehicle, the odometer reading on this was:
and to the best of my knowledge reflected the actual odometer reading on this vehicle. This is to certify that I am aware of the
facts contained in the above Statements of Facts from the seller. I further agree to indemnify the Tennessee Department
of Revenue for any and all losses which it might suffer due to the existence of facts to the contrary of those contained in this
certification.
Under penalties of perjury, I hereby certify this information is correct to the best of my knowledge.
SIGNATURE OF CERTIFIER/PURCHASER
PURCHASER MUST HAND PRINT NAME
TELEPHONE NUMBER & AREA CODE
DATE
PURCHASER'S STREET ADDRESS
CITY & STATE
IMPORTANT NOTICE
Certifications should be obtained from all owners involved since the discrepancy in the odometer reading recording
occurred. Also, persons appointed by a power of attorney cannot complete this certification.
RV-F1310801 (Rev. 6-04)
SELLER'S STATEMENT OF FACTS:
I,
RDA 692
