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ODOMETER DISCLOSURE STATEMENT

Revised 7/2017 ODOMETER DISCLOSURE STATEMENT The form may only be used when: 1. Certificate of Title is to be issued by court order; 2. a dealer has voided an assignment on a Manufacturer s STATEMENT of Origin and is attempting to reassign; 3. a law enforcement agency is making application for Certificate of Title to an Abandoned Vehicle; 4. submitting an Affidavit of transfer of Decedent s Motor Vehicle and the previous Certificate of Title is not available; 5. making application for a Storage-Repair Lien. Federal and State law requires that the seller 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. VEHICLE DESCRIPTION Year Make Model Body Type Vehicle Identification Number I, certify to the best of my knowledge that the ODOMETER (Print or Type Seller s Name) reading is the actual mileage of the vehicle unless one of the statements below is checked: ODOMETER Reading: The mileage stated is in excess of mechanical limits.

2. a dealer has voided an assignment on a Manufacturer’s Statement of Origin and is attempting to reassign; 3. a law enforcement agency is making application for Certificate of Title to an Abandoned Vehicle; 4. submitting an Affidavit of Transfer of Decedent’s Motor Vehicle and the previous Certificate of Title is not available; 5.

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