Odometer And Damage Disclosure Statement {MV-103}

New York State Department of Motor Vehicles ODOMETER AND DAMAGE DISCLOSURE STATEMENT FEDERAL AND STATE LAWS REQUIRE THAT YOU PROVIDE THE MILEAGE AND CONDITION OF THE VEHICLE DESCRIBED BELOW WHEN TRANSFERRING OWNERSHIP OF IT TO SOMEONE ELSE. IF YOU DO NOT GIVE THE MILEAGE AND CONDITION INFORMATION TO THE NEW OWNER, OR IF YOU GIVE FALSE MILEAGE INFORMATION, YOU MAY BE SUBJECT TO FINES AND/OR IMPRISONMENT. Odometer Disclosure Statement Enter odometer reading exactly as it appears on the vehicle's odometer (excluding tenths) and check applicable boxes. The vehicle described below is equipped with an odometer that (please check one): ODOMETER READING o ______ has five digits, excluding tenths (NO TENTHS) o ______ has six digits, excluding tenths o 1. o 2. o 3. I certify that, to the best of my knowledge, this odometer reading reflects the ACTUAL MILEAGE as seen on the odometer of the vehicle described below. I certify that, to the best of my knowledge, this odometer reading "EXCEEDS MECHANICAL LIMITS." (Odometer started over at zero) I certify that, to the best of my knowledge, this odometer reading is "NOT THE ACTUAL MILEAGE. WARNING - ODOMETER DISCREPANCY." Damage Disclosure Statement - Check One Box Making a false statement or failing to accurately disclose the salvage status of a vehicle may subject you to substantial civil fines in addition to any penalties under the Penal Law. I certify that, to the best of my knowledge, this vehicle has been or has not been wrecked, destroyed or damaged to such an extent that the total estimate, or actual cost, of parts and labor to rebuild or reconstruct the vehicle to the condition it was in before an accident, and for legal operation on the road or highways, is more than 75% of the retail value of the vehicle at the time of loss. (Checking the "has" box means that the vehicle must have an anti-theft examination before being registered and that the title issued will have the statement "Rebuilt Salvage: NY" on it.) Vehicle Year Make Model Body Type Vehicle Identification Number Seller's Signature ç Mailing Address (Include Street Number and Name, Rural Delivery, Box, Apt. No.) City or Town New Owner's Signature Seller's Name (Print Name in Full) State Zip Code Date of Statement ç Mailing Address (Include Street Number and Name, Rural Delivery, Box, Apt. No.) City or Town New Owner's Name (Print Name in Full) State Zip Code Date of Statement MV-103 (5/11) Skip the Trip! Do Your DMV Business On-Line At: www.dmv.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com