Odometer Disclosure Statement

Tom Orlando Lorain County Clerk of Court of Common Pleas ODOMETER DISCLOSURE STATEMENT Title Division Ohio and Federal law requires that you state the mileage upon transfer of a motor vehicle. Failure to complete or providing a false statement may result in the fines and/or imprisonment. I, _________________________________________________________________________________________________ (Transferor/Seller Name) State that the odometer now reads: Thousands , Hundreds .X And to the best of my knowledge It reflects the actual mileage of the vehicle described below, unless one of the following statements is checked. I hereby certify that to the best of my knowledge the odometer reading reflects an amount of mileage in excess of its mechanical limits. I hereby certify that the odometer reading is NOT the actual mileage. WARNING ­ ODOMETER DISCREPANCY. VEHICLE IDENTIFICATION MAKE MODEL BODY TYPE VEHICLE IDENTIFICATION NUMBER YEAR TRANSFEROR'S SIGNATURE (SELLER) PRINTED NAME TRANSFEROR'S STREET ADDRESS CITY DATE OF STATEMENT STATE ZIP CODE TRANSFEREE'S SIGNATURE (SELLER) PRINTED NAME TRANSFEREE'S STREET ADDRESS CITY DATE OF STATEMENT American LegalNet, Inc. www.FormsWorkFlow.com STATE ZIP CODE