ODOMETER MILEAGE STATEMENT 


IMPORTANT: Federal regulations require this statement to be given 
to purchasers on sales of vehicles. An inaccurate or untrue 
statement may make you liable for damages to the buyer and there 
may also be civil or criminal penalties. 

______________________, state that the odometer described below 
now reads ___________________.


Certify one of the following-- please "XXX" the appropriate line 
before the correct statement: 



___________ I (we) certify that to the best of my (our) knowledge 
the odometer reading as stated above reflects the actual mileage 
of the vehicle described below. 


___________ I (we) certify that to the best of my (our) knowledge 
the odometer reading as stated above reflects the amount of 
mileage in excess of designed mechanical limits of 99,999 miles of
 the vehicle described below. 


___________ I (we) certify that to the best of my (our) knowledge 
the odometer reading as stated above is NOT the actual mileage of 
the vehicle described below, and should not be relied upon. 


MAKE: ____________

MODEL ____________

BODY TYPE ________

YEAR: ____________

VEHICLE IDENTIFICATION NUMBER: __________________ 


Certify one of the following-- please "XXX" the appropriate line 
before the correct statement: 


__________ I (we) certify that the odometer of the vehicle 
described above was not altered, set back, or disconnected while 
in my (our) possession, and I (we) have no knowledge of anyone 
else doing so. 


__________ I (we) certify that the odometer was alerted for repair
 or replacement purposes while in my (our) possession, and that
the  mileage registered on the repaired or replaced odometer is 
identical to that before such service. 


__________ I (we) certify that if the repaired or replacement 
odometer was incapable of registering the same mileage, that it 
was reset to zero, and that the mileage on the original odometer  

or the odometer before repair was __________________ miles. 



SELLER (Transferor) address: 

____________________________________
____________________________________

Date of statement: ___________________________ 





___________________________________________________ 


BUYER (Transferee) name and address: 


____________________________________________________
____________________________________________________
____________________________________________________




Receipt of copy acknowledged: 





____________________________________________