49 CFR Part 580, Appendix E to Part 580 - Power of Attorney Disclosure Form

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View PDF at GPO Pt. 580, App. 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]

Title 49 published on 2014-10-01

no entries appear in the Federal Register after this date.

Title 49 published on 2014-10-01

The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 49 CFR 580 after this date.

  • 2015-01-23; vol. 80 # 15 - Friday, January 23, 2015
    1. 80 FR 3538 - Federal Motor Vehicle Safety Standards; Small Business Impacts of Motor Vehicle Safety
      GPO FDSys XML | Text
      DEPARTMENT OF TRANSPORTATION, National Highway Traffic Safety Administration
      Notice of regulatory review; Request for comments.
      You should submit comments early enough to ensure that Docket Management receives them not later than March 24, 2015.
      49 CFR Parts 571, 580, 581, 582, 583, 585, 587, and 588