49 C.F.R. § 580 app D to Part 580
Odometer Disclosure Statement (Leased Vehicle)
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 imprisonment. Complete disclosure form below and return to lessor.
I,______ (name of person making disclosure, 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.
Make____________________
Model____________________
Body Type____________________
Vehicle Identification Number____________________
Year____________________
Lessee's Name____________________
Lessee's Address____________________
(Street)
____________________
(City) (State) (ZIP Code)
Lessee's Signature____________________
Date of Statement____________________
Lessor's Name____________________
Lessor's Address____________________
(Street)
____________________
(City) (State) (ZIP Code)
Date Disclosure Form Sent to Lessee____________________
Date Completed Disclosure Form Received from Lessee____________________
Lessor's Signature____________________
49C.F.R. 580 app D to Part 580