Appendix D to Part 580 - Disclosure Form for Leased Vehicle
49:7.1.1.1.9.0.1.18.15 : Appendix D
Appendix D to Part 580 - Disclosure Form for Leased Vehicle
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