Appendix C to Part 580 - Separate Disclosure Form
49:7.1.1.1.9.0.1.18.14 : Appendix C
Appendix C to Part 580 - Separate Disclosure Form 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.
Make Model Body Type Vehicle Identification Number Year
(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)