Transcription of Odometer/Mileage Disclosure Statement
1 YearMakePlease complete, sign and submit the form by Fax: 1-877-501-7620 Or mail: chase AutoODOMETER Disclosure Statement (LEASED VEHICLES)Federal law (and State law, if applicable) requires that the lessee disclose the mileage to the lessor in connection with the transfer of ownership. Failure to complete or making a false Statement may result in fines and/or returning or purchasing your leased vehicle, please complete, sign and return Disclosure form below to JPMorgan chase Bank, (print name of person making Disclosure ), state that the odometer now reads(no tenths) further state the following (please place a checkmark next to only one of the following statements):I certify that, to the best of my knowledge, the above-listed odometer reading reflects the ACTUAL MILEAGE of the vehicle described certify that, to the best of my knowledge, the above-listed odometer reading reflects the amount of mileage IN EXCESS OF ITS MECHANICAL certify that the above-listed odometer reading is NOT the actual mileage.
2 CALIFORNIA LESSEES: I certify, under penalty of perjury under the laws of the State of California, the foregoing odometer information is true and correct. 700 Kansas LaneMail Code LA4-4025 Monroe, LA 71203 Lessee s Name and Address Information: HICLE _____ _____ STATEZIP Lessee Name: Lessee Address: CITY Lessee s Signature: _____ Date of Statement : _____ The Odometer Disclosure Statement cannot be altered in any way. Please do not strike through any information, use white-out, or check any incorrect boxes. If any information needs to be corrected, please use a new NOT WRITE BELOW THIS LINEM odelVehicle Identification Number (VIN) Body Type (select one): Convertible CoupeSedanSUVO ther TruckLessor s Name: _____JPMorgan chase Bank, s Address: _____Chase Auto, 700 Kansas Lane, Mail Code LA4-4025, Monroe, LA 71203 _____Date Disclosure Form sent to Lessee: _____ Date Completed Disclosure Form Received from Lessee: _____ Lessor s Signature: _____ Name and Title: _____Version (21-047-F) 8/21
