Odometer Disclosure Statement f1317001 - …

1 TENNESSEE DEPARTMENT OF REVENUEODOMETER Disclosure STATEMENTFEDERAL and STATE LAW requires that you state the mileage in connection with the transfer of ownership. Failure tocomplete or providing a false Statement may result in fines and/or ,SELLER OR TRANSFEROR S NAME (PLEASE PRINT)certify to the best of my knowledge that the Odometer reading on the vehicle described below is the actual mileage of thevehicle unless one of the following statements is checked: Odometer READING (NO TENTHS)1I hereby certify that the mileage stated is in excess of the mechanical limits of the Odometer reading is not the actual mileage. WARNING - Odometer TYPEVEHICLE IDENTIFICATION NUMBERYEARSELLER OR TRANSFEROR S ADDRESSCITYSTATEZIP CODESELLER OR TRANSFEROR S SIGNATUREDATE OF THIS STATEMENTXBUYER OR TRANSFEREE S NAME (PLEASE PRINT)BUYER OR TRANSFEREE S ADDRESSCITYSTATEZIP CODEBUYER OR TRANSFEREE S SIGNATUREXRV- f1317001 (Rev.)

2 4-05)RDA-692 TAXPAYER AND VEHICLE SERVICES DIVISIONTENNESSEE DEPARTMENT OF REVENUEODOMETER Disclosure STATEMENTFEDERAL and STATE LAW requires that you state the mileage in connection with the transfer of ownership. Failure tocomplete or providing a false Statement may result in fines and/or ,SELLER OR TRANSFEROR S NAME (PLEASE PRINT)certify to the best of my knowledge that the Odometer reading on the vehicle described below is the actual mileage of thevehicle unless one of the following statements is checked: Odometer READING (NO TENTHS)1I hereby certify that the mileage stated is in excess of the mechanical limits of the Odometer reading is not the actual mileage.

3 WARNING - Odometer TYPEVEHICLE IDENTIFICATION NUMBERYEARSELLER OR TRANSFEROR S ADDRESSCITYSTATEZIP CODESELLER OR TRANSFEROR S SIGNATUREDATE OF THIS STATEMENTXBUYER OR TRANSFEREE S NAME (PLEASE PRINT)BUYER OR TRANSFEREE S ADDRESSCITYSTATEZIP CODEBUYER OR TRANSFEREE S SIGNATUREXRV- f1317001 (Rev. 4-05)RDA-692 OWNERTENNESSEE DEPARTMENT OF REVENUEODOMETER Disclosure STATEMENTFEDERAL and STATE LAW requires that you state the mileage in connection with the transfer of ownership. Failure tocomplete or providing a false Statement may result in fines and/or ,SELLER OR TRANSFEROR S NAME (PLEASE PRINT)certify to the best of my knowledge that the Odometer reading on the vehicle described below is the actual mileage of thevehicle unless one of the following statements is checked: Odometer READING (NO TENTHS)1I hereby certify that the mileage stated is in excess of the mechanical limits of the Odometer reading is not the actual mileage.

4 WARNING - Odometer TYPEVEHICLE IDENTIFICATION NUMBERYEARSELLER OR TRANSFEROR S ADDRESSCITYSTATEZIP CODESELLER OR TRANSFEROR S SIGNATUREDATE OF THIS STATEMENTXBUYER OR TRANSFEREE S NAME (PLEASE PRINT)BUYER OR TRANSFEREE S ADDRESSCITYSTATEZIP CODEBUYER OR TRANSFEREE S SIGNATUREXRV- f1317001 (Rev. 4-05)RDA-692 COUNTY CLERK