Odometer Discrepancy Statement - TN.gov

1 TENNEESSEE DEPARTMENT OF REVENUE RV-F1310801 (Rev. 3-21). Odometer Discrepancy Statement PURPOSE: The seller can explain and certify any discrepancies that may have occured regarding the Odometer . The purchaser can certify that they understand the circumstances. INSTRUCTIONS: The seller and purchaser must complete the respective portions below in their entirety. A. Seller's Statement of Facts: This is to certify that on _____, I, _____ sold the following described vehicle (VIN, Make, Model and Year) _____ to _____. Seller's Street Address: _____. City: _____ State: _____ Zip: _____ Phone: _____. This is to also certify that at the time that I sold/transferred this vehicle, the Odometer reading on this vehicle was: _____ and to the best of my knowledge reflected the correct Odometer reading.

2 In error, the documents pertaining to the transfer of ownership of this vehicle reflected an incorrect Odometer reading due to the following reason(s): _____. B. Seller's Certification: Under Federal Law, making an inaccurate or untruthful Statement may make you liable for civil damages and for civil or criminal penalties, pursuant to the Motor Vehicle Information and Cost Savings Act of 1972 (Pub. L. 92-513. as amended by Pub. L. 99-5769). Under penalties of perjury, I hereby certify this information is correct to the best of my knowledge. Seller's Signature: _____ Printed Name: _____ Date: _____. C. Purchaser's Statement of Facts: This is to certify that on _____, I, _____ purchased the following described vehicle (VIN, Make, Model and Year) _____ from: _____.

3 Purchaser's Street Address: _____. City: _____ State: _____ Zip: _____ Phone: _____. This is to also certify that at the time that I purchased this vehicle, the Odometer reading on this vehicle was: _____ and to the best of my knowledge reflected the correct Odometer reading. In error, the documents pertaining to the transfer of ownership of this vehicle reflected an incorrect Odometer reading due to the following reason(s): _____. D. Purchaser's Certification: Under Federal Law, making an inaccurate or untruthful Statement may make you liable for civil damages and for civil or criminal penalties, pursuant to the Motor Vehicle Information and Cost Savings Act of 1972 (Pub.)

4 L. 92-513. as amended by Pub. L. 99-5769). Under penalties of perjury, I hereby certify this information is correct to the best of my knowledge. Purchaser's Signature: _____ Printed Name: _____ Date: _____. IMPORTANT NOTICE. Certifications should be obtained from all owners involved since the Discrepancy in the Odometer reading recording occurred. Also, persons appointed by a power of attorney cannot complete this certification. RDA 692.