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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