(Customer Name) (no tenths) miles and to the best of my ...
ODOMETER DISCLOSURE STATEMENT (LEASED VEHICLE)
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. Complete disclosure form below and return to lessor.
I,____________ , state that the odometer now reads
(Customer 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 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.
Year Body Type
Make Vehicle Identification Number
Model
Lessee's Name (Print) Lessee's Street Address City
State
ZIP Code
Lessee's Signature
Date of Statement
Lessor's Name
U.S. Bank N.A.
Lessor's Street Address
1850 Osborn Ave
City
Oshkosh__________WI
State
54902
Lessor's Signature_________________________________Date_____________Statement Sent to Lessee
ZIP Code
Print Name of Above Signature
U.S. Bank N.A. By:
Date
Statement Received from Lessee
Member FDIC
158940731/16/2019
CAT-
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