Appendix B to Part 580 - Disclosure Form for Title
49:7.1.1.1.9.0.1.18.13 : Appendix B
Appendix B to Part 580 - Disclosure Form for Title Odometer
Disclosure Statement
Federal law (and State law, if applicable) requires that you
state the mileage in connection with the transfer of ownership.
Failure to complete or providing a false statement may result in
fines and/or imprisonment.
I 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 herein, 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) (Transferee's Signature) (Printed name)
(Printed name) Date of Statement Transferee's Name Transferee's
Address (Street) (City) (State) (ZIP Code)