Odometer 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: _____________________________