OODOMETERDI

SCLOSURESTATEMENT
*
*COMPANYOFMOTORVEHI
CLES

I
NSTRUCTI
ONS: 1. Inaccordancewi t
hfederalandstatelaw,thesel
lerofamot orvehicl
emustdiscl
osethecurrentmileaget
oapurchaserin
wri
tingupont r
ansferofownership.Thediscl
osuremustbesi gnedbyt hesel
l
er,i
ncludi
ngthepr i
ntedname.Ifmoret
hanone
personisasel l
er,onl
yonesel l
erisrequir
edtosignt hewr
it
tendisclosur
e.
2. Thepur chasermustsignthedisclosurest
atement,incl
udi
ngpr i
ntednameandaddr ess,andretur
nacopyt othesel
ler
.
3. Compl etethi
sforminitsenti
ret
y,inblueorblackink.

FederalandSt
atel
awr equi
rest
hatyoust
atethemileageupont
ransf
erofowner
shi
p.Fai
l
uret
ocompl
eteorpr
ovi
dingaf
alse
st
atementmayresul
tinfi
nes,i
mpri
sonment,orbot
h.

I
, r
esi
dingat
:
Pr
int
edname(
s)ofSel
l
er(
s)

cer
ti
fyt
othebestofmyknowl
edget
hatt
he
Addr
essofSel
l
ers)(
( numberandst
reet
,ci
ty,st
ate,andZI
Pcode)

odomet
err
eadi
ngi
stheact
ualmi
l
eageoft
hevehi
cl
edescr
ibedbel
owunl
essoneoft
hef
oll
owi
ngst
atement
sischecked:

es(
Mi
l not
ent
hs) 1. Iher
ebycer
ti
fyt
hatt
othebestofmyknowl
edget
heodomet
err
eadi
ngr
efl
ect
stheamountof
mil
eagei
nexcessofi
tsmechani
call
i
mit
s.
2. Iher
ebycer
ti
fyt
hatt
heodometerr
eadi
ngi
sNOTt
heact
ualmi
l
eageandshoul
dnotber
eli
edupon.
WARNING-ODOMETERDI SCREPANCY.

Vehi
cl
eMake Vehi
cl
eModel Vehi
cl
eYear Vehi
cl
eBodyType

Vehi
cl
eIdent
if
icat
ionNumber(
VIN) Tr
ansf e(
erDat mont
h,day,year
)

Iwil
lnothol
dt heBureauofMotorVehi
clesort
heBureauofMot orVehicl
esCommissi
onr
esponsi
blef
oranydi
screpancyshownon
theodometerreadi
ng.I,t
heundersi
gned,swearoraf
fi
rmthattheinf
ormati
onent
eredont
hisf
ormiscorr
ect
.Iunderst
andthat
makingafalsestat
ementmayconstit
utethecr
imeofperj
ury.
Si
gnat
ure(
s)ofSel
l
er(
s) e(
Dat mont
h,day,year
)

PURCHASER’
SINFORMATI
ON

Iam awar
eofandacknowl
edget
heaboveodomet
ercer
ti
fi
cat
ionmadebyt
hesel
l
er(
s).
Si
gnat
ure(
s)ofPur
chaser
(s) e(
Dat mont
h,day,year
)

Pr
int
edName(
s)ofPur
chas
er(
s)

Addr
essofPur
chaser
(s)(
numberandst
reet
)

Ci
ty St
ate ZI
PCode