Anthony J. Dattilio Columbiana County Clerk of Courts Odometer Disclosure Statement Federal law (and State law, if applicable) requires that you state the mileage upon transfer of ownership. Failure to compleor te providing a false statement may result in fines and/or imprisonment. I, ________________________________________________________________, state that the odometer (of the vehicle described below) now reads ____________________________________________ (no tenths) miles and to the best of my knowledge that it reflects the actual mileage of the vehicle deriscbed below, unless one of the following statements is checked. (1) I hereby certify that to the best of my knowledge the odometer reading reflects mileage in excess of its mechanical limits. (2) I he reby certify that the odometer reading is NOT the actual mileage. WARNING - ODOMETER DISCREPANCY Make Body Type Model Vehicle ID Number Year Transferors Printed Name (Seller) Transferors Street Address City S tate Z ip code Date of statement X Transferors Signature (Seller) X Printed name of person signing (Seller) Transferees Printed Name (Buyer) Street Address City S tate Z ip code Receipt of Copy Acknowledged X Transferees signature (Buyer) Date X Printed Name of Person Signing (Buyer) Federal law requires buyer and seller to keep a copy of this form Originals to the Clerk of Courts American LegalNet, Inc. www.USCourtForms.com