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