Odometer Statement

Odometer Disclosure Statement Federal and State law require that you state the odometer mileage upon transfer of ownership. Failure to complete or providing a false statement may result in fines and/or imprisonment. TO BE COMPLETED BY THE SELLER I/We _____________________________________ state that the odometer mileage indicated for the Vehicle described below is: ___________________ (check one) Miles Kilometers Hours. And I/We hereby certify to the best of my/our knowledge that (check one statement below that is applicable) (1) the odometer reading is the actual mileage. (2) the odometer reading reflects the amount of mileage in excess of its mechanical limits. (3) the odometer reading is not actual mileage. Warning ­ Odometer discrepancy. Year of Manufacture Make Body Type Model Vehicle Identification Number Printed Name of Seller: Address of Seller: Seller's Signature: Seller's Certification Date: TO BE COMPLETED BY THE BUYER Printed Name of Transferee (Buyer): Address of Buyer: Buyer's Signature: Date Completed Form Received: American LegalNet, Inc. www.FormsWorkFlow.com