IMPORTANT:  Federal regulations require this statement to be given to purchasers on sales of vehicles.  An inaccurate or untrue statement may make you liable for damages to the buyer and there may also be civil or criminal penalties.

Current Owner:_______________________________________ , state that the odometer described below now reads_____________________________miles.


Certify one of the following-- please place an "X" the appropriate line before the correct statement:

___________ I (we) certify that to the best of my (our) knowledge the odometer reading as stated above reflects the actual mileage of the vehicle described below.

___________ I (we) certify that to the best of my (our) knowledge the odometer reading as stated above reflects the amount of mileage in excess of designed mechanical limits of 99,999 miles of the vehicle described below.

___________ I (we) certify that to the best of my (our) knowledge the odometer reading as stated above is NOT the actual mileage of the vehicle described below, and should not be relied upon.

MAKE:_______________________________MODEL:_________________________________

 BODY TYPE:_____________________ YEAR:______________

 VEHICLE IDENTIFICATION NUMBER:______________________________________________________

 Certify one of the following -- please place an "X" the appropriate line before the correct statement:

__________ I (we) certify that the odometer of the vehicle described above was not altered, set back, or disconnected while in my (our) possession, and I (we) have no knowledge of anyone else doing so.

__________ I (we) certify that the odometer was alerted for repair or replacement purposes while in my (our) possession, and that the mileage registered on the repaired or replaced odometer is identical to that before such service.


__________ I (we) certify that if the repaired or replacement odometer was incapable of registering the same mileage, that it was reset to zero, and that the mileage on the original odometer

or the odometer before repair was __________________ miles.

SELLER (Transferor)
 
 Name:______________________________________

Address:___________________________________

City:______________________________________ST:_______Zip:___________

 
 Date of statement: ___________________________

BUYER (Transferee)
 
 Name:______________________________________

Address:___________________________________

City:______________________________________ST:_______Zip:____________

 
 Receipt of copy acknowledged:

____________________________________________