ODOMETER DISCLOSURE STATEMENT Vehicle)

[Pages:1]KENTUCKY TRANSPORTATION CABINET Department of Vehicle Regulation

DIVISION OF MOTOR VEHICLE LICENSING

TC 96-4 Rev. 05/2020

Page 1 of 1

ODOMETER DISCLOSURE STATEMENT (Leased Vehicle)

INSTRUCTIONS: Please complete this form and attach it to your Title and Registration application documents and forward to your County Court Clerk. Also, send a copy of the completed form to the lessor.

County Clerk information may be accessed at .

Note: Federal law requires that the lessee disclose the mileage to the lessor in connection with the transfer of ownership. Failure to disclose or making a false statement may result in fines and/or imprisonment.

SECTION 1: LESSEE STATEMENT

I,

, state that the odometer now reads

(Name of Person Making Disclosure)

(No. tenths)

miles and, to the best of my knowledge, reflects the actual mileage of the vehicle described below unless one of the following statements is checked.

I hereby certify to the best of my knowledge that the odometer reading reflects mileage in excess of its mechanical limits.

I hereby certify that the odometer reading is NOT the actual mileage.

SECTION 2: LESSEE INFORMATION NAME

ADDRESS

CITY

STATE ZIP

PHONE

SIGNATURE (lessee)

DATE OF STATEMENT

SECTION 3: NOTARIZATION

Subscribed and attested before me on this date

. My commission expires

MM DD YYYY

MM DD YYYY

Attesting Official or Notary Signature and Title

SECTION 4: VEHICLE INFORMATION

MAKE

MODEL

My commission #: BODY TYPE

VEHICLE IDENTIFICATION #

YEAR

SECTION 5: LESSOR INFORMATION NAME

CITY

DATE DISCLOSURE SENT TO LESSEE

SIGNATURE (lessor)

STATE

ADDRESS

ZIP

PHONE

DATE COMPLETED DISCLOSURE RETURNED FROM LESSEE

DATE OF STATEMENT

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