Fillable TENNESSEE DEPARTMENT OF REVENUE ODOMETER DISCLOSURE STATEMENT FEDERAL (Tennessee County Clerk)

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TENNESSEE DEPARTMENT OF REVENUE ODOMETER DISCLOSURE STATEMENT FEDERAL (Tennessee County Clerk)

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TENNESSEE DEPARTMENT OF REVENUE
ODOMETER DISCLOSURE STATEMENT
FEDERAL and STATE LAW requires that you state the mileage in connection with the transfer of ownership. Failure to
complete or providing a false statement may result in fines and/or imprisonment.
I,
SELLER OR TRANSFEROR’S NAME (PLEASE PRINT)
certify to the best of my knowledge that the odometer reading on the vehicle described below is the actual mileage of the
vehicle unless one of the following statements is checked:
ODOMETER READING (NO TENTHS)
1 I hereby certify that the mileage stated is in excess of the mechanical limits of the odometer.
2 The odometer reading is not the actual mileage. WARNING - ODOMETER DISCREPANCY.
MAKE
MODEL
BODY TYPE
VEHICLE IDENTIFICATION NUMBER
YEAR
SELLER OR TRANSFEROR’S ADDRESS
CITY
STATE ZIP CODE
SELLER OR TRANSFEROR’S SIGNATURE
DATE OF THIS STATEMENT
X
BUYER OR TRANSFEREE’S NAME (PLEASE PRINT)
BUYER OR TRANSFEREE’S ADDRESS
CITY
STATE ZIP CODE
BUYER OR TRANSFEREE’S SIGNATURE
X
RV-F1317001 (Rev. 4-05)
RDA-692
TAXPAYER AND VEHICLE SERVICES DIVISION
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Reset
TENNESSEE DEPARTMENT OF REVENUE
ODOMETER DISCLOSURE STATEMENT
FEDERAL and STATE LAW requires that you state the mileage in connection with the transfer of ownership. Failure to
complete or providing a false statement may result in fines and/or imprisonment.
I,
SELLER OR TRANSFEROR’S NAME (PLEASE PRINT)
certify to the best of my knowledge that the odometer reading on the vehicle described below is the actual mileage of the
vehicle unless one of the following statements is checked:
ODOMETER READING (NO TENTHS)
1 I hereby certify that the mileage stated is in excess of the mechanical limits of the odometer.
2 The odometer reading is not the actual mileage. WARNING - ODOMETER DISCREPANCY.
MAKE
MODEL
BODY TYPE
VEHICLE IDENTIFICATION NUMBER
YEAR
SELLER OR TRANSFEROR’S ADDRESS
CITY
STATE ZIP CODE
SELLER OR TRANSFEROR’S SIGNATURE
DATE OF THIS STATEMENT
X
BUYER OR TRANSFEREE’S NAME (PLEASE PRINT)
BUYER OR TRANSFEREE’S ADDRESS CITY
STATE ZIP CODE
BUYER OR TRANSFEREE’S SIGNATURE
X
RV-F1317001 (Rev. 4-05)
RDA-692
OWNER
TENNESSEE DEPARTMENT OF REVENUE
ODOMETER DISCLOSURE STATEMENT
FEDERAL and STATE LAW requires that you state the mileage in connection with the transfer of ownership. Failure to
complete or providing a false statement may result in fines and/or imprisonment.
I,
SELLER OR TRANSFEROR’S NAME (PLEASE PRINT)
certify to the best of my knowledge that the odometer reading on the vehicle described below is the actual mileage of the
vehicle unless one of the following statements is checked:
ODOMETER READING (NO TENTHS)
1 I hereby certify that the mileage stated is in excess of the mechanical limits of the odometer.
2 The odometer reading is not the actual mileage. WARNING - ODOMETER DISCREPANCY.
MAKE
MODEL
BODY TYPE
VEHICLE IDENTIFICATION NUMBER
YEAR
SELLER OR TRANSFEROR’S ADDRESS
CITY
STATE
ZIP CODE
SELLER OR TRANSFEROR’S SIGNATURE
DATE OF THIS STATEMENT
X
BUYER OR TRANSFEREE’S NAME (PLEASE PRINT)
BUYER OR TRANSFEREE’S ADDRESS
CITY
STATE ZIP CODE
BUYER OR TRANSFEREE’S SIGNATURE
X
RV-F1317001 (Rev. 4-05)
RDA-692
COUNTY CLERK
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TENNESSEE DEPARTMENT OF REVENUE ODOMETER DISCLOSURE STATEMENT FEDERAL (Tennessee County Clerk)

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Completed 2 June 2021

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