49 CFR Part 580, Appendix C to Part 580 - Separate Disclosure Form

View PDF at GPO Pt. 580, App. 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)

Title 49 published on 2014-10-01

no entries appear in the Federal Register after this date.