Odometer disclosure statement document with fields for make, mod…

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, 1- - I} 1 man r 1Crxy 1-.7 v. hrrtpf STATE THAT 4 A L (TRANFEFSOR S'NAME- sEE'LE'R P}: V ' THE ODOMETEFI NOW READS MILES AND TO THE OMETEFI READING (NO TENTHsI BEST OF MY KNOWLEDGE THAT IT REFLECTS THE ACTUAL MILEAGE OF THE VEHICLE DESCRIBED BELOW, UNLESS ONE OF THE FOLLOWING STATEMENTS IS CHECKED. D (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. D (2) I HEREBY CERTIFY THAT THE ODOMETER READING IS NOT THE ACTUAL MILEAGE. WARNING - ODOMETER DISCREPANCY. MAKE MODEL BODY TYPE Arm 1 VEHICLE"IBEIITIFICATION No. ~ * 'YEAFI DEALER STOCK NO '7 , I) (PRINTED NAMEI 5:717 m; HTFLIA pr Ignrzwc TRANSFEROR'S STREET ADDRESS (SELLER) T/I DOTTFTIT' 1-1:: (CITYT " "' (STATE) (ZIP CODE) DATEOE TATEMERT i .4 E .'v '3 , i; 76365:: S SIGNATUWW PWNTED NAME) TRANSFEHEES NAME (BUYER) aw: :L'J. .L L L.) SCI-Lug TRAMFI2EEYRE ETRDDRESSIBEJV'Ep L a ' (CITVD 5 :3 _ SKI FR. {STATE} (ZIP CODE) . fawn 3355: TT ,, 1-: x 1 .LJ 3007 :1 580.6 REV. 3/89 ORIGINAL- TRANSFEREE (BUYER)