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84-001-1139 (5/12)
ODOMETER DISCLOSURE STATEMENT
Federal law (and State law, if applicable) requires that you state the mileage upon 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, __________________________________________________________________ (lessee's name, Print) state that the odometer now reads ________________ (no tenths).
Check ONE item only:
(1) I hereby certify that to the best of my knowledge the odometer reading as stated above reflects the actual mileage of the vehicle described below.
(2) I hereby certify that to the best of my knowledge the odometer reading reflects the amount of mileage in excess of its mechanical limits.
(3) I hereby certify that the odometer reading is NOT the actual mileage. WARNING: ODOMETER DISCREPANCY.
YEAR
MAKE
MODEL
BODY TYPE
VEHICLE IDENTIFICATION NUMBER
ACCOUNT NO.
LESSEE'S NAME AND ADDRESS
DATE OF STATEMENT (CURRENT DATE) LESSEE'S SIGNATURE
X CO-LESSEE'S NAME AND ADDRESS
DATE OF STATEMENT (CURRENT DATE) CO-LESSEE'S SIGNATURE
X LESSOR'S NAME AND ADDRESS
DATE DISCLOSURE FORM SENT TO LESSEE LESSOR'S SIGNATURE
X
DATE COMPLETED DISCLOSURE FORM RECEIVED FROM LESSEE
................
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