ODOMETER DISCLOSURE STATEMENT VSA 5 (07/01/2021)

1 VSA 5 (07/01/2021) BUYER STREET ADDRESSCITYSTATEZIP CODEODOMETER DISCLOSURE STATEMENT Do not use this form if a title exists for this vehicle. Purpose: Use this form to comply with state and federal laws that require the seller of a motor vehicle to state the ODOMETER mileage upon transfer of ownership . Instructions: Print or Type - Failure to complete or providing false information may result in fines and/or imprisonment. (Sections 409, 412 and 413 of the Motor Vehicle Information and Cost Savings Act of 1972, Section of the Code of Virginia.) VEHICLE INFORMATIONMAKEBODY TYPEMODELVEHICLE IDENTIFICATION NUMBERYEARSELLER CERTIFICATIONBUYER CERTIFICATIONBUYER NAME (print)BUYER SIGNATUREDATE (mm/dd/yyyy) By signing below I acknowledge and certify that I have received a copy of this completed form. I certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate.

2 I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false STATEMENT or representation on this form is a criminal the ODOMETER reading of the vehicle in the box to the right and check one of the following statements. CHECK ONE BOX ONLY: ODOMETER READING (no tenths) ODOMETER reading entered is THE ACTUAL MILEAGE OF THE VEHICLE ODOMETER reading entered is IN EXCESS OF ODOMETER 'S MECHANICAL LIMITS ODOMETER reading entered IS NOT THE ACTUAL MILEAGE. (WARNING- ODOMETER Discrepancy)Vehicle was exempt from DISCLOSURE in prior state of title (applicant must present out-of-state title showing exemption)SELLER NAME (print)SELLER STREET ADDRESSCITYSTATEZIP CODESELLER SIGNATUREDATE (mm/dd/yyyy)