Transcription of Odometer Disclosure Statement
1 kentucky transportation CABINET DIVISION OF MOTOR VEHICLE LICENSING TC 96 5 Rev. 06/2015 Page 1 of 1 Odometer Disclosure Statement Instructions: Attach this form to your title and registration application documents and forward to your county clerk. Note: Federal law requires that you state the mileage upon transfer of ownership. Failure to complete or providing a false Statement may result in fines and imprisonment under KY Odometer law KRS SECTION 1: VEHICLE INFORMATION YEAR MAKE MODEL VIN BODY TYPE SECTION 2: TRANSFEROR/SELLER INFORMATION & Statement NAME (Please print.) PHONE ( ) ADDRESS I, state that the Odometer now reads miles and to the (Transferor/Seller s name) (no tenths) best of my knowledge reflects the actual mileage of the vehicle described above unless one of the following statements is checked. I hereby certify that to the best of my knowledge the Odometer reflects mileage in excess of its mechanical limits.
2 I hereby certify that the Odometer reading is NOT the actual mileage. WARNING Odometer DISCREPANCY SIGNATURE DATE SECTION 3: CERTIFICATION Subscribed and attested before me on this day of 20 . Notary/Attesting Official Signature and Title My Commission expires MM DD YYYY SECTION 4: TRANSFEREE/BUYER INFORMATION NAME PHONE ( ) ADDRESS SIGNATURE DATE
