Odometer Disclosure Statement - DPSMV1606

[Pages:1]LOUISIANA DEPARTMENT OF PUBLIC SAFETY OFFICE OF MOTOR VEHICLES

ODOMETER DISCLOSURE STATEMENT

Federal and State law require that you state the mileage upon transfer of ownership. Failure to complete or providing a false statement may result in fine and/or imprisonment.

I, __________________ certify that the odometer now reads _________

Seller (Print name)

(no tenths)

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 IN EXCESS OF ITS MECHANICAL LIMITS.

______ (2) I hereby certify that the odometer reading is NOT THE ACTUAL MILEAGE. WARNING - ODOMETER DISCREPANCY.

Make_________________Model________________Body Type___________

Year _______________

Vehicle Identification Number _____________________________________

SELLER'S Signature _____________________________________________

Printed Name of Seller ____________________________________________

Seller's Address _________________________________________________

(Street)

_______________________________________________________________

(City)

(State)

(ZIP Code)

BUYER's Signature ______________________________________________

Printed Name of Buyer ___________________________________________

Representative Name (of Company) _________________________________

Buyer's Address _________________________________________________

(Street)

_______________________________________________________________

(City)

(State)

(ZIP Code)

Date of Statement________________________________________________

DPSMV 1606 (R 10/94)

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