Appendix E to Part 580 - Power of Attorney Disclosure Form
49:7.1.1.1.9.0.1.18.16 : Appendix E
Appendix E to Part 580 - Power of Attorney Disclosure Form
Warning: This form may be used only when title is physically
held by lienholder or has been lost. This form must be submitted to
the state by the person exercising powers of attorney. Failure to
do so may result in fines and/or imprisonment.
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]