CAUTION: DO NOT CHECK IF ACTUAL MILEAGE - Potter County

STATEMENT OF FACTS

TO CORRECT ERROR ON TITLE

NO ALTERATION, WHITE OUT, OR ERRORS ARE ACCEPTABLE ON THIS FORM

This is to state that an error was made on Title #

Year

Make

VIN

The reason for the error was:

Assignment

or

Odometer Reading

or

Other:

It is now correct as sold to:

NAME

ADDRESS

Date of Sale:

Federal and State laws require 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 state that the odometer now reads

(no tenths) miles as to the best of my

knowledge that it reflects the actual mileage of the vehicle described herein, unless one of the

following statements is checked:

CAUTION: DO NOT CHECK IF ACTUAL MILEAGE

I hereby certify that to the best of my knowledge the odometer reading

reflects the amount of mileage in excess of its mechanical limits.

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

WARNING - ODOMETER DISCREPANCY

Transferor¡¯s/Seller¡¯s Signature

Transferor¡¯s/Seller¡¯s Printed Name

Transferee¡¯s/Buyer¡¯s Signature

Transferee¡¯s/Buyer¡¯s Printed Name

*NOTE: This affidavit may not be acceptable when filed with jurisdictions other than Texas.

WARNING: TRANSPORTATION CODE ¡ì501.155, PROVIDES THAT

FALSIFYING INFORMATION ON ANY REQUIRED STATEMENT OR

APPLICATION IS A THIRD - DEGREE FELONY.

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