Fill and Sign the Odometer Statement Form

ODOMETER DISCLOSURE STATEMENTTo be completed by Transferor (Seller) Federal law (and State law, if applicable) requires 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, _______________________________ , state that the odometer now reads _______________ miles 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. I hereby certify that to the best of my knowledge the odometer reading reflects the amount of mileage in excess of its mechanical limits. I hereby certify that the odometer reading is NOT the actual mileage. WARNING - ODOMETER DISCREPANCY. Make _______________ Model _______________ Body Type _______________ Vehicle Identification Number (VIN) _______________ Year: _______________ Signature of Transferor (Seller): __________________________ Transferor's (Seller's) Information Transferor's Name (Please Type or Print): Street Address: City: State: Zip: Transferee's (Buyer's) Information Transferee's Name (Please Type or Print): Street Address: City: State: Zip: Signature of Transferee (Buyer): ____________________________ DATE OF STATEMENT: STATE OF COUNTY OF SWORN TO AND SUBSCRIBED BEFORE ME, this the _____ day of ____________ ___, 20_____. ____________________________ NOTARY PUBLIC My Commission Expires: ________________________ ORIGINAL MUST BE PROVIDED WITH APPLICATION FOR A CERTIFICATE OF TITLE