49 C.F.R. Appendix E to Part 580—Power of Attorney Disclosure Form
Title 49 - Transportation
VEHICLE DESCRIPTION Year ____ Make _______ Model _______ Body Type _______ Vehicle Identification Number ____________ Part A. Power of Attorney To Disclose Mileage Federal law (and State Law, if applicable) requires that you state the mileage upon transfer of ownership. Providing a false statement may result in fines and/or imprisonment. I, _______________ (transferor's name, Print) appoint _______________ (transferee's name, Print) as my attorney-in-fact, to disclose the mileage, on the title for the vehicle described above, exactly as stated in my following disclosure. I state that the odometer now reads ______ (no tenths) miles and to the best of my knowledge that it reflects the actual mileage unless one of the following statements is checked. __ (1) I hereby certify that to the best of my knowledge the odometer reading reflect the 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) 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) _____. Part B. Power of Attorney To Review Title Documents and Acknowledge Disclosure. (Part B is invalid unless Part A has been completed.) I, _______________ (transferee's name, Print) appoint _______________ (transferor's name, Print) as my attorney-in-fact, to sign the mileage disclosure, on the title for the vehicle described above, only if the disclosure is exactly as the disclosure completed below. (Transferee's Signature) (Printed Name) Transferee's Name ____________ Transferee's Address (Street) ____________ (City) ______ (State) __ (ZIP Code) _____. Federal law (and State Law, if applicable) requires that you state the mileage upon transfer of ownership. 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 unless one of the following statements is checked. __ (1) I hereby certify that to the best of my knowledge the odometer reading reflect the 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) Transferor's Address (Street) ____________ (City) ______ (State) __ (ZIP Code) _____. Date of Statement ________ Part C. Certification (To Be Completed When parts A and B Have Been Used) I, ________, (person exercising above powers of attorney, Print), hereby certify that the mileage I have disclosed on the title document is consistent with that provided to me in the above power of attorney. Further, upon examination of the title and any reassignment documents for the vehicle described above, the mileage diclosure I have made on the title pursuant to the power of attorney is greater than that previously stated on the title and reassignment documents. This certification is not intended to create, nor does it create any new or additional liability under Federal or State law. (Signature) ________________________________ (Printed Name) Address (Street) (City) ________ (State) __ (ZIP Code) _____ Date ________ [54 FR 9816, Mar. 8, 1989, as amended at 54 FR 35889, Aug. 30, 1989]
Title 49: Transportation
PART 580—ODOMETER DISCLOSURE REQUIREMENTS
Appendix E to Part 580—Power of Attorney Disclosure Form