Odometer Disclosure Statement f1317001
[Pages:3]TENNESSEE DEPARTMENT OF REVENUE ODOMETER DISCLOSURE STATEMENT
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FEDERAL and STATE LAW requires that you state the mileage in connection with the transfer of ownership. Failure to complete or providing a false statement may result in fines and/or imprisonment.
I, SELLER OR TRANSFEROR'S NAME (PLEASE PRINT)
certify to the best of my knowledge that the odometer reading on the vehicle described below is the actual mileage of the vehicle unless one of the following statements is checked:
ODOMETER READING (NO TENTHS)
1 I hereby certify that the mileage stated is in excess of the mechanical limits of the odometer. 2 The odometer reading is not the actual mileage. WARNING - ODOMETER DISCREPANCY.
MAKE
MODEL
BODY TYPE
VEHICLE IDENTIFICATION NUMBER
YEAR
SELLER OR TRANSFEROR'S ADDRESS
X
SELLER OR TRANSFEROR'S SIGNATURE
CITY
BUYER OR TRANSFEREE'S NAME (PLEASE PRINT)
BUYER OR TRANSFEREE'S ADDRESS
X
BUYER OR TRANSFEREE'S SIGNATURE
CITY
STATE
ZIP CODE
DATE OF THIS STATEMENT
STATE
ZIP CODE
RV-F1317001 (Rev. 4-05)
TAXPAYER AND VEHICLE SERVICES DIVISION
RDA-692
TENNESSEE DEPARTMENT OF REVENUE ODOMETER DISCLOSURE STATEMENT
FEDERAL and STATE LAW requires that you state the mileage in connection with the transfer of ownership. Failure to complete or providing a false statement may result in fines and/or imprisonment.
I, SELLER OR TRANSFEROR'S NAME (PLEASE PRINT)
certify to the best of my knowledge that the odometer reading on the vehicle described below is the actual mileage of the vehicle unless one of the following statements is checked:
ODOMETER READING (NO TENTHS)
1 I hereby certify that the mileage stated is in excess of the mechanical limits of the odometer. 2 The odometer reading is not the actual mileage. WARNING - ODOMETER DISCREPANCY.
MAKE
MODEL
BODY TYPE
VEHICLE IDENTIFICATION NUMBER
YEAR
SELLER OR TRANSFEROR'S ADDRESS
X
SELLER OR TRANSFEROR'S SIGNATURE
CITY
BUYER OR TRANSFEREE'S NAME (PLEASE PRINT)
BUYER OR TRANSFEREE'S ADDRESS
X
BUYER OR TRANSFEREE'S SIGNATURE
CITY
STATE
ZIP CODE
DATE OF THIS STATEMENT
STATE
ZIP CODE
RV-F1317001 (Rev. 4-05)
OWNER
RDA-692
TENNESSEE DEPARTMENT OF REVENUE ODOMETER DISCLOSURE STATEMENT
FEDERAL and STATE LAW requires that you state the mileage in connection with the transfer of ownership. Failure to complete or providing a false statement may result in fines and/or imprisonment.
I, SELLER OR TRANSFEROR'S NAME (PLEASE PRINT)
certify to the best of my knowledge that the odometer reading on the vehicle described below is the actual mileage of the vehicle unless one of the following statements is checked:
ODOMETER READING (NO TENTHS)
1 I hereby certify that the mileage stated is in excess of the mechanical limits of the odometer. 2 The odometer reading is not the actual mileage. WARNING - ODOMETER DISCREPANCY.
MAKE
MODEL
BODY TYPE
VEHICLE IDENTIFICATION NUMBER
YEAR
SELLER OR TRANSFEROR'S ADDRESS
X
SELLER OR TRANSFEROR'S SIGNATURE
CITY
BUYER OR TRANSFEREE'S NAME (PLEASE PRINT)
BUYER OR TRANSFEREE'S ADDRESS
X
BUYER OR TRANSFEREE'S SIGNATURE
CITY
STATE
ZIP CODE
DATE OF THIS STATEMENT
STATE
ZIP CODE
RV-F1317001 (Rev. 4-05)
COUNTY CLERK
RDA-692
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