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VTR-40 (Rev. 6/2005) DHT # 142235

ODOMETER DISCLOSURE STATEMENT

Federal and State Law require that you state the mileage in connection with the transfer of ownership. Failure to complete or providing a false statement may result in fines and/or imprisonment. This form may not be used in conjunction with title transfer documents, which comply with federal and state odometer disclosure requirements such as Texas Certificate of Titles issued on or after April 29, 1990.

VEHICLE DESCRIPTION

Year	Make	Modal	Body style
Vehicle Identification Number

I,certify to the best of my knowledge that the odometer reading is the actual

(Seller/Agent Name)

mileage of the vehicle described above unless one of the following statements is checked:

VAGE DAVTYAN (No Tenths)

1. The mileage stated is in excess of its mechanical limits 2. The odometer reading is not the actual mileage. WARNING – ODOMETER DISCREPANCY.

Date of Statement	Signature of Seller/Agent	Printed Name (Same as Signature)

If titled in a firm’s name, print the firm’s name on the line above.

Street Address	city	State	Zip Code

ACKNOWLEDGMENT OF ODOMETER DISCLOSURE BY BUYER/AGENT

Vehicle Identification Number	Signature of Seller/Agent	Printed Name (Same as Signature)
I am aware of the above odometer certification made by the seller/agent. Date of Statement	Signature of Buyer/Agent	Printed Name (Same as Signature)