49 CFR Appendix C to Part 580, Separate Disclosure Form

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.

Body Type
Vehicle Identification Number
(Transferor's Signature)
(Printed name)
Transferor's Address
(City) (State) (ZIP Code)
Date of Statement
(Transferee's Signature)
(Printed name)
Transferee's Name
Transferee's Address
(City) (State) (ZIP Code)

This is a list of United States Code sections, Statutes at Large, Public Laws, and Presidential Documents, which provide rulemaking authority for this CFR Part.

This list is taken from the Parallel Table of Authorities and Rules provided by GPO [Government Printing Office].

It is not guaranteed to be accurate or up-to-date, though we do refresh the database weekly. More limitations on accuracy are described at the GPO site.

United States Code