ODOMETER DISCLOSURE STATEMENT
ODOMETER DISCLOSURE
STATEMENT
The form may only be used when:
1. Certificate of Title is to be issued by court order;
2. a dealer has voided an assignment on a Manufacturer¡¯s Statement of Origin and is attempting
to reassign;
3. a law enforcement agency is making application for Certificate of Title to an Abandoned
Vehicle;
4. submitting an Affidavit of Transfer of Decedent¡¯s Motor Vehicle and the previous Certificate
of Title is not available;
5. making application for a Storage-Repair Lien.
Federal and State law requires that the seller state the mileage in connection with the Transfer of
Ownership. Failure to complete, or providing a false statement, may result in fines and/or
imprisonment.
VEHICLE DESCRIPTION
Year
Make
Model
Body Type
Vehicle Identification Number
I,
certify to the best of my knowledge that the odometer
(Print or Type Seller¡¯s Name)
reading is the actual mileage of the vehicle unless one of the statements below is checked:
Odometer Reading:
The mileage stated is in excess of mechanical limits.
Reading is NOT actual mileage ¨C WARNING ODOMETER DISCREPANCY
SELLER INFORMATION
BUYER INFORMATION
Please Print
Please Print
City
Seller¡¯s Signature
Name
Name
Address
Address
State
Zip
Date
City
Buyer¡¯s Signature
State
Zip
Date
SELLER MUST RETAIN A COPY OF THIS STATEMENT FOR 5 YEARS
Revised 7/2017
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