49 CFR Appendix C to Part 580 - Appendix C to Part 580—Separate Disclosure Form

Odometer Disclosure Statement

Federal law (and State law, if applicable) requires that you state the mileage upon transfer of ownership. Failure to complete or providing a false statement may result in fines and/or imprisonment.

I, ____________ (transferor's name, Print) state that the odometer now reads ________ (no tenths) miles and to the best of my knowledge that it reflects the actual mileage of the vehicle described below, unless one of the following statements is checked.

—(1) I hereby certify that to the best of my knowledge the odometer reading reflects the amount of mileage in excess of its mechanical limits.

—(2) I hereby certify that the odometer reading is NOT the actual mileage. WARNING—ODOMETER DISCREPANCY.

Make

Model

Body Type

Vehicle Identification Number

Year

(Transferor's Signature)

(Printed name)

Transferor's Address

(Street)

(City) (State) (ZIP Code)

Date of Statement

(Transferee's Signature)

(Printed name)

Transferee's Name

Transferee's Address

(Street)

(City) (State) (ZIP Code)