Odometer/Mileage Disclosure Statement - Chase
Instructions for Completing the Odometer Disclosure Statement
? The form must be filled out completely and accurately. ? Do not alter this form ? no corrections or cross-outs. Do not use white-out. ? Do not print double-sided. ? If you need to make a correction, please download a new form at:
? See arrows below for important details.
Enter lessee's name. Printed name and
signature must match lease statement.
Check one of the boxes ONLY if the mileage entered above is not the actual mileage, otherwise leave blank.
Enter lessee's name as it appears in the line above.
Do not write in or sign this section.
Please complete, sign, and submit the form via email at title.management@. Or Fax: 1-877-501-7620 Or mail: Chase Auto, 700 Kansas Lane, Mail-Code LA4-4042, Monroe, LA 71203.
ODOMETER DISCLOSURE STATEMENT (LEASED VEHICLES)
Federal law (and State law, if applicable) requires that the lessee disclose the mileage to the lessor in connection with the transfer of ownership. Failure to complete or making a false statement may result in fines and/or imprisonment.
When returning or purchasing your leased vehicle, please complete, sign and return disclosure form below to JPMorgan Chase Bank, N.A.
I ________________________________________ (print name of person making disclosure), state that the odometer now reads _____________ (no tenths) miles and that 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.
EXAMPLE 1. I certify that, to the best of my knowledge, the above-listed odometer reading reflects the amount of mileage IN EXCESS OF ITS MECHANICAL LIMITS. 2. I certify that the above-listed odometer reading is NOT the actual mileage.
Year
Make
Model
Vehicle Identification Number (VIN)
Body Type (select one):
Convertible
Coupe
Sedan
SUV
Truck Other
Lessee's Name and Address Information:HICLE Lessee Name: Lessee Address:
CITY
STATE
ZIP
Lessee's Signature: _______________________________________________________________ Date of Statement: _______________________________________________________________
DO NOT WRITE BELOW THIS LINE
Lessor's Name: __J_P_M__o_r_g_a__n__C_h_a__s_e__B_a_n__k_,_N__.A__.____________________________________________________________________________ Lessor's Address: _C__h_a_s_e__A__u_t_o_,_7_0__0_K__a_n_s_a__s_L__a_n_e_,__M__a_il_C__o_d__e_L__A_4_-_4_0__4_2_,_M__o__n_r_o_e_,_L__A__7_1_2_0__3________________________________
Date Disclosure Form sent to Lessee: _________________________________________________________________________________________ Date Completed Disclosure Form Received from Lessee: _________________________________________________________________________ Lessor's Signature: _______________________________________________________________________________________________________ Name and Title: ______________________________________________________________________________________________
Version 6.B (22-090-B) 8/22
Enter current mileage of the vehicle. Do not include tenths of a mile.
(For example: 47000.2 should be entered as 47000)
Accurately enter vehicle Year, Make, Model and VIN details. Check appropriate Body Type box.
Lessee's signature must match names printed above.
The directions contained herein are intended to help reduce clerical errors and do not constitute legal
advice from JPMorgan Chase Bank, N.A. If you have a question regarding how to complete the form
you should consult with your own legal counsel.
(22-090-B) 8/22
Please complete, sign, and submit the form via email at title.management@ Or Fax: 1-877-501-7620 Or mail: Chase Auto, 700 Kansas Lane, Mail-Code LA4-4042, Monroe, LA 71203.
ODOMETER DISCLOSURE STATEMENT (LEASED VEHICLES)
Federal law (and State law, if applicable) requires that the lessee disclose the mileage to the lessor in connection with the transfer of ownership. Failure to complete or making a false statement may result in fines and/or imprisonment. When returning or purchasing your leased vehicle, please complete, sign and return disclosure form below to JPMorgan Chase Bank, N.A.
I ________________________________________ (print name of person making disclosure), state that the odometer now reads _____________ (no tenths) miles and that 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.
1. I certify that, to the best of my knowledge, the above-listed odometer reading reflects the amount of mileage IN EXCESS OF ITS MECHANICAL LIMITS.
2. I certify that the above-listed odometer reading is NOT the actual mileage.
Year
Make
Model
Vehicle Identification Number (VIN)
Body Type (select one):
Convertible
Coupe
Sedan
SUV
Truck Other
Lessee's Name and Address Information:HICLE Lessee Name: Lessee Address:
CITY
STATE
ZIP
Lessee's Signature: _______________________________________________________________ Date of Statement: _______________________________________________________________
DO NOT WRITE BELOW THIS LINE
Lessor's Name: __J_P_M__o_r_g_a__n__C_h_a__s_e__B_a_n__k_,_N__.A__.____________________________________________________________________________ Lessor's Address: _C__h_a_s_e__A__u_t_o_,_7_0__0_K__a_n_s_a__s_L__a_n_e_,__M__a_il_C__o_d__e_L__A_4_-_4_0__4_2_,_M__o__n_r_o_e_,_L__A__7_1_2_0__3________________________________
Date Disclosure Form sent to Lessee: _________________________________________________________________________________________ Date Completed Disclosure Form Received from Lessee: _________________________________________________________________________ Lessor's Signature: _______________________________________________________________________________________________________ Name and Title: ______________________________________________________________________________________________
Version 6.B (22-090-B) 8/22
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