Odometer/Mileage Disclosure Statement
If you are purchasing* your vehicle:
If you are returning your vehicle:
Please complete and fax to: 888-295-8891 OR Attach form to check and send to: HCA Exchange, Inc. Dept. CH 14301 Palatine, IL 60055-4301
A. Print form B. Bring along to vehicle turn-in C. Complete and sign at dealer
Odometer/Mileage Disclosure Statement
Complete the Information Below
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, __________________________ (name of person making disclosure, Print) state that the odometer now reads ________________ (no tenths) miles and to the best of my knowledge:
Please check only one box and sign below:
I hereby certify that the odometer reading reflects the actual mileage of the vehicle described below; or
I hereby certify that the odometer reading reflects the amount of mileage in excess of its mechanical limits; or
I hereby certify that the odometer reading is NOT the actual mileage and should not be relied upon
Make Model Body Type VIN (Vehicle Information Number) Year Lessee's Name(s) Lessee's Address Lessee's Signature(s) Date of Statement
DO NOT WRITE BELOW THIS LINE -------------------------------------
-------------------------------------
Lessor's Name
Lessor's Address
Date Disclosure Form sent to Lessee
Date Completed Disclosure Form Received from Lessee
Lease Account Number
Lessor's Signature
Name & Title
Notice is hereby given that the rights, but not the obligations, of Hyundai Lease Titling Trust ("HLTT") under the sale agreement for the asset described in this agreement have been assigned to HCA Exchange, Inc. pursuant to an agreement between HLTT and HCA Exchange, Inc. *If state allows direct purchase. 3869.3.01/19/2020
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