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 : 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 STATEMENTI, FORMTEXT ?????, state that the odometer now reads FORMTEXT ?????(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. FORMCHECKBOX I hereby certify to the best of my knowledge that the odometer reading reflects mileage in excess of its mechanical limits. FORMCHECKBOX I hereby certify that the odometer reading is NOT the actual mileage.SECTION 2: LESSEE INFORMATIONNAME FORMTEXT ?????ADDRESS FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ?????ZIP FORMTEXT ?????PHONE FORMTEXT ?????SIGNATURE (lessee)DATE OF STATEMENT FORMTEXT ?????SECTION 3: NOTARIZATIONSubscribed and attested before me on this date. My commission expiresMMDD YYYYMMDDYYYYMy commission #:Attesting Official or Notary Signature and TitleSECTION 4: VEHICLE INFORMATIONMAKE FORMTEXT ?????MODEL FORMTEXT ?????BODY TYPE FORMTEXT ?????VEHICLE IDENTIFICATION # FORMTEXT ?????YEAR FORMTEXT ?????SECTION 5: LESSOR INFORMATIONNAME FORMTEXT ?????ADDRESS FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ?????ZIP FORMTEXT ?????PHONE FORMTEXT ?????DATE DISCLOSURE SENT TO LESSEE FORMTEXT ?????DATE COMPLETED DISCLOSURE RETURNED FROM LESSEE FORMTEXT ?????SIGNATURE (lessor)DATE OF STATEMENT FORMTEXT ????? ................
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