This odometer disclosure statement can be completed by a car seller and buyer to record how many miles are on the vehicle.
Odometer Disclosure Statement
Federal and State law require that you state the odometer mileage upon transfer of ownership. Failure to complete or providing a false statement may result in fines and/or imprisonment.
To be completed by the seller:
I/we {name} state that the odometer mileage indicated for the vehicle described below is {number} miles/kilometers/hours.
And I/we hereby certify to the best of my/our knowledge that (check one statement below that is applicable)
1) the odometer reading is the actual mileage.
2) the odometer reading reflects the amount of mileage in excess of its mechanical limits.
3) the odometer reading is not actual mileage. Warning - odometer discrepancy.
Year of Manufacture _____________
Make ____________
Body Type _____________
Model ____________
Vehicle Identification Number _____________________________
Printed Name of Seller: _____________________________
Address of Seller: _____________________________
Seller's Signature: _____________________________
Seller's Certification Date: _____________________________
To be completed by the buyer:
Printed name of transferee (buyer): _____________________________
Address of Buyer: _____________________________
Buyer's Signature: _____________________________
Date Completed Form Received: _____________________________
