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Seller's Signature Seller's Name (Print Name in Full) Mailing Address (Include Street Number and Name, Rural Delivery, Box, Apt. No.) Enter odometer reading exactly as it appears on the vehicle's odometer (excluding tenths) and check applicable boxes.
Odometer mileage disclosure statements do not need to be given for vehicles having a gross vehicle weight rating of 16,000 pounds or more, vehicles 20 years old or older, or vehicles sold directly by the manufacturer to any agency of the United States Government (UCA §41-1a-902).
Information contained in the odometer mileage disclosure statement includes the following: The odometer reading at the time of transfer, The date of transfer, The transferor's name and address or the transferor's authorized agent's name and address if the transferor is a company,
City State Zip code Street address Date of statement Transferee's signature Federal and State law require that you furnish to the transferee a written odometer disclosure statement upon transfer of ownership.