State of Ohio Applicants Affidavit Odometer Reading Disclosure Stat ement (Type or Print in Ink) Erasures & Alterations void this statement Notice to applicant for certificate of title: You are required by law to enter all information required herein, including the odometer reading of this motor vehicle in the affidavit immediately following. The making of a false statement under oath or affirmation is in violation of section 2921.12 of the Ohio Revised Code and is punishable by six months imprisonment and a fine of up to one Thousand dollars, or both. State of Ohio, County SS: Date Year Mfrs serial no. Make Model Body type Motor no. Purchasers name Check one of the following statements. I(We) certify that: I(We) have made every effort possible and cannot locate the previous owner of the above described motor vehicle to obtain the odometer statement required by Section 4505.06 of the Ohio Revised Code I(We) obtained ownership of the above described motor vehicle by operation of law pursuant to Sections 4505.10;4513.61 or 4513.62 of the Ohio Revised Code, and at the time of transfer of ownership was not able to obtain a statement of the odometer reading from the previous owner. The above described motor vehicle (check one) is _____ newly assembled, ____ is presently evidenced by a salvage certificate of title, or _____ was previously registered/titled in another state, province or country and (check one of the following:) To the best of my(our) knowledge, the odometer reading reflects the actual mileage The odometer reading reflects mileage in excess of the designed mechanical limit of 99,999 miles To the best of my(our) knowledge, the odometer reading is not the actual mileage and should not be relied upon. I(we) certify that the mileage registered on the odometer of this motor vehicle at the time of application for title is miles. (Must be completed) Applicants signature Sworn to and subscribed in my presence by: this day of 20____ My commission expires: seal (Clerk, Deputy Clerk of Courts - Notary Applicants affidavit American LegalNet, Inc. www.USCourtForms.com>>>> 2 Do Not Detach from Title Erasures & Alterations Void This Statement State of Ohio Sellers Affidavit Odometer Reading Disclosure Statement (Type or Print in Ink) Notice to transferor: You are required by law to enter all information required herein, including the odometer reading of this motor vehicle in the affidavit immediately following. The making of a false statement under oath or affirmation is in violation of section 2921.12 of the Ohio Revised Code and is punishable by six months imprisonment and a fine of up to one Thousand dollars, or both. State of Ohio, County SS Date Year M frs serial no. Make Model Body type Motor no . Purchasers name I(we) certify that the mileage registered on the odometer of this motor vehicle at the time of application for title is _____________________ miles Check one of the following statements. I(We) certify that: To the best of my(our) knowledge, the odometer reading reflects the actual mileage The odometer reading reflects mileage in excess of the designed mechanical limit of 99,999 miles To the best of my(our) knowledge, the odometer reading is not the actual mileage and should not be relied upon. Check one of the following, I(We) certify that, while in my(our) possession: The odometer of this vehicle was not altered, set back or disconnected The odometer of this vehicle was repaired or replaced Transferors signature Sworn to and subscribed in my presence by: this day of 20____ My commission expires: seal (Clerk, Deputy Clerk of Courts - Notary American LegalNet, Inc. www.USCourtForms.com