Leasee Address

ODOMETER DISCLOSURE STATEMENT (Lease Vehicle)

NOTE FEDERAL LAW requires that you state the mileage to the lessor in connection with transfer of ownership. Failure to complete this disclosure statement or providing false information may result in fines and/or imprisonment. Complete the disclosure form below and return it to the lessor when you lease is terminated.

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.

[ ] (1) I hereby certify that to the best of my knowledge the odometer reading reflects the amount of mileage is in excess of its mechanical limits.

[ ] (2) I hereby certify that the odometer reading is NOT the actual mileage.

Year: ________ Make: _____________ Model: _________________ Color: _______________ VIN: ________________________________ Leasee Name: ___________________________________ Leasee Address:

___________________________________ ___________________________________

Lessee Signature: _______________________________________ Date ________ Lessee Printed Name: _________________________________________________

Dealer Section: Did they purchase or lease a new Volvo? __________________________

If No, What did make/model?________________ Are they terminating the lease early or normal termination? ______ Early Termination or ______ Normal Termination Are they part of Volvo's Pull Ahead Program? ___________ If Yes, VIN FOR THE NEW VOLVO _____________________________________

How many KEYS were returned? ________ Owners Manual: ________

Employee Handling this lease return: ___________________

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