Odometer Disclosure Statement (Leased Vehicle)

Federal law (and State law, if applicable) requires that the lessee disclose the mileage to the lessor in connection with the transfer of ownership. Failure to complete or making a false statement may result in fines and/or imprisonment. Complete disclosure form below and return to lessor.

I,____________ (name of person making disclosure, 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.

Make Model Body Type Vehicle Identification Number Year Lessee's Name Lessee's Address (Street) (City) (State) (ZIP Code) Lessee's Signature Date of Statement Lessor's Name Lessor's Address (Street) (City) (State) (ZIP Code) Date Disclosure Form Sent to Lessee Date Completed Disclosure Form Received from Lessee Lessor's Signature