ODOMETER DISCLOSURE STATEMENT (Leased Vehicle) - Ally

[Pages:1]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 the making of a false statement may result in fines and/or imprisonment. Complete the disclosure form below and return it to the lessor when your lease is terminated.

I,

Print name of person making disclosure

state that the odometer now reads

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.

Make Model Body Type Vehicle Identification Number Year Lessee's Name Lessee's Address

(Street)

Lessee's Signature

(City)

Date of Statement

Lessor's Name

Lessor's Address

(State) (Street)

(Zip Code)

(City)

Date Disclosure Form Sent to Lessee

(State)

Date Completed Disclosure Form Received from Lessee

Lessor's Signature

(Zip Code)

5040 7/2010 Copyright 2010 Ally Financial. All Rights Reserved

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