49 C.F.R. Appendix C to Part 580—Separate Disclosure Form
Title 49 - Transportation
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. (Transferor's Signature) (Printed name) (Street) (City) (State) (ZIP Code) (Transferee's Signature) (Printed name) (Street) (City) (State) (ZIP Code)
Title 49: Transportation
PART 580—ODOMETER DISCLOSURE REQUIREMENTS
Appendix C to Part 580—Separate Disclosure Form
Model____________________
Body Type____________________
Vehicle Identification Number____________________
Year____________________
____________________
____________________
Transferee's Address____________________