49 C.F.R. § D to Part 580

Current through October 31, 2024
Appendix D to Part 580 - Disclosure Form for Leased Vehicle

Odometer Disclosure Statement (Leased Vehicle)

Federal law (and State law, if applicable) requires that the lessee disclose the mileage to the lessor in connection with the transfer of ownership. Failure to complete or making a false statement may result in fines and/or imprisonment. Complete disclosure form below and return to lessor.

I,____________ (name of person making disclosure, Print) state that the odometer now 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.

Make _______________________________

Model _______________________________

Body Type _______________________________

Vehicle Identification Number _______________________________

Year _______________________________

Lessee's Name _______________________________

Lessee's Address _______________________________

(Street)

_______________________________

(City) (State) (ZIP Code)

Lessee's Signature _______________________________

Date of Statement _______________________________

Lessor's Name _______________________________

Lessor's Address _______________________________

(Street)

_______________________________

(City) (State) (ZIP Code)

Date Disclosure Form Sent to Lessee _______________________________

Date Completed Disclosure Form Received from Lessee _______________________________

Lessor's Signature _______________________________

49 C.F.R. §D to Part 580