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|[pic] |OHIO DEPARTMENT OF PUBLIC SAFETY | |

| |BUREAU OF MOTOR VEHICLES | |

| | | |

| |ODOMETER DISCLOSURE STATEMENT | |

|Federal law (and State law), if applicable) requires that you state the mileage upon transfer of ownership. Failure to complete or providing a false statement may |

|result in fines and/or imprisonment. |

|I, |      |state that the odometer (of the vehicle described below) now |

| |PRINT TRANSFEROR’S NAME | |

|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. |

| |WARNING - ODOMETER DISCREPANCY. |

|MAKE |BODY TYPE |MODEL |

|      |      |      |

|VEHICLE ID NUMBER |YEAR |

|      |      |

|TRANSFEROR’S PRINTED NAME (SELLER) |

|      |

|TRANSFEROR’S STREET ADDRESS |

|      |

|CITY |STATE |ZIP CODE |

|      |      |      |

|DATE OF STATEMENT |TRANSFEROR’S SIGNATURE (SELLER) |

|      |X |

| |PRINTED NAME OF TRANSFEROR |

| |      |

|TRANSFEREE’S PRINTED NAME (BUYER) |

|      |

|TRANSFEREE’S STREET ADDRESS |

|      |

|CITY |STATE |ZIP CODE |

|      |      |      |

|RECEIPT OF COPY ACKNOWLEDGED |

|TRANSFEREE’S SIGNATURE (BUYER) |PRINTED NAME OF TRANSFEREE |

|X |      |

www.bmv.ohio.gov

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