Odometer Disclosure Statement



Instructions: Attach this form to your title and registration application documents and forward to your county clerk.County Clerk information may be accessed at : Federal law requires that you state the mileage upon transfer of ownership. Failure to complete or providing a false statement may result in fines and imprisonment under KY odometer law KRS 190.300. SECTION 1: VEHICLE INFORMATIONYEAR FORMTEXT ????MAKE FORMTEXT ?????MODEL FORMTEXT ?????VIN FORMTEXT ?????BODY TYPE FORMTEXT ?????SECTION 2: TRANSFEROR/SELLER INFORMATION & STATEMENTNAME (Please print.) FORMTEXT ?????PHONE( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????ADDRESS FORMTEXT ?????I, FORMTEXT ?????state that the odometer now reads FORMTEXT ?????miles and to the (Transferor/Seller’s name)(no tenths)best of my knowledge reflects the actual mileage of the vehicle described above unless one of the following statements is tris checked. FORMCHECKBOX I hereby certify that to the best of my knowledge the odometer reflects mileage in excess of its mechanical limits. FORMCHECKBOX I hereby certify that the odometer reading is NOT the actual mileage. WARNING-ODOMETER DISCREPANCYSIGNATUREDATESECTION 3: CERTIFICATIONSubscribed and attested before me on thisday of20.Notary/Attesting Official Signature and TitleMy commission #:My commission expires//MMDDYYYYSECTION 4: TRANSFEREE/BUYER INFORMATIONNAME FORMTEXT ?????PHONE( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????ADDRESS FORMTEXT ?????SIGNATUREDATE ................
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