49 C.F.R. § 580 app C to Part 580
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)
49C.F.R. 580 app C to Part 580