Odometer/Mileage Disclosure Statement

Please complete, sign and submit the form by Fax: 1-877-501-7620 Or mail: Chase Auto

700 Kansas Lane Mail Code LA4-4025 Monroe, LA 71203

ODOMETER DISCLOSURE STATEMENT (LEASED VEHICLES)

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.

When returning or purchasing your leased vehicle, please complete, sign and return disclosure form below to JPMorgan Chase Bank, N.A.

I ________________________________________ (print name of person making disclosure), state that the odometer now reads _____________ (no tenths) miles. I further state the following (please place a checkmark next to only one of the following statements):

I certify that, to the best of my knowledge, the above-listed odometer reading reflects the ACTUAL MILEAGE of the vehicle described below.

I certify that, to the best of my knowledge, the above-listed odometer reading reflects the amount of mileage IN EXCESS OF ITS MECHANICAL LIMITS.

I certify that the above-listed odometer reading is NOT the actual mileage.

CALIFORNIA LESSEES: I certify, under penalty of perjury under the laws of the State of California, the foregoing odometer information is true and correct.

Year

Make

Model

Vehicle Identification Number (VIN)

Body Type (select one):

Convertible

Coupe

Lessee's Name and Address Information:HICLE Lessee Name: Lessee Address:

Sedan

SUV

Truck Other

CITY

STATE

ZIP

Lessee's Signature: _______________________________________________________________

Date of Statement: _______________________________________________________________

The Odometer Disclosure Statement cannot be altered in any way. Please do not strike through any information, use white-out, or check any incorrect boxes. If any information needs to be corrected, please use a new form.

DO NOT WRITE BELOW THIS LINE

Lessor's Name: __J_P_M__o_r_g_a__n__C_h_a__s_e__B_a_n__k_,_N__.A__.____________________________________________________________________________ Lessor's Address: _C__h_a_s_e__A__u_t_o_,_7_0__0_K__a_n_s__a_s__L_a_n_e__, _M__a_il__C_o_d__e__L_A_4__-4__0_2_5_,__M_o__n_r_o_e_,_L__A__7_1_2__0_3________________________________

Date Disclosure Form sent to Lessee: _________________________________________________________________________________________ Date Completed Disclosure Form Received from Lessee: _________________________________________________________________________ Lessor's Signature: _______________________________________________________________________________________________________ Name and Title: ______________________________________________________________________________________________

Version 3.B (21-047-F) 8/21

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