Form VSA5 "Odometer Disclosure Statement" - Virginia

What Is Form VSA5?

This is a legal form that was released by the Virginia Department of Motor Vehicles - a government authority operating within Virginia. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2021;
  • The latest edition provided by the Virginia Department of Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form VSA5 by clicking the link below or browse more documents and templates provided by the Virginia Department of Motor Vehicles.

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Download Form VSA5 "Odometer Disclosure Statement" - Virginia

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ODOMETER DISCLOSURE STATEMENT
VSA 5 (07/01/2021)
Do not use this form if a title exists for this vehicle.
Purpose:
Use this form to comply with state and federal laws that require the seller of a motor vehicle to state the odometer mileage upon transfer
of ownership.
Instructions:
Print or Type - Failure to complete or providing false information may result in fines and/or imprisonment. (Sections 409, 412 and 413 of
the Motor Vehicle Information and Cost Savings Act of 1972, Section 46.2-629 of the Code of Virginia.)
VEHICLE INFORMATION
VEHICLE IDENTIFICATION NUMBER
MAKE
BODY TYPE
MODEL
YEAR
SELLER CERTIFICATION
Enter the odometer reading of the vehicle in the box to the right and check one of the following statements.
ODOMETER READING (no tenths)
CHECK ONE BOX ONLY:
Odometer reading entered is THE ACTUAL MILEAGE OF THE VEHICLE
Odometer reading entered is IN EXCESS OF ODOMETER'S MECHANICAL LIMITS
Odometer reading entered IS NOT THE ACTUAL MILEAGE. (WARNING-Odometer Discrepancy)
Vehicle was exempt from disclosure in prior state of title (applicant must present out-of-state title showing exemption)
I certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the
information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand
that knowingly making a false statement or representation on this form is a criminal violation.
SELLER NAME (print)
DATE (mm/dd/yyyy)
SELLER SIGNATURE
SELLER STREET ADDRESS
CITY
STATE
ZIP CODE
BUYER CERTIFICATION
By signing below I acknowledge and certify that I have received a copy of this completed form.
BUYER NAME (print)
BUYER SIGNATURE
DATE (mm/dd/yyyy)
BUYER STREET ADDRESS
CITY
STATE
ZIP CODE
ODOMETER DISCLOSURE STATEMENT
VSA 5 (07/01/2021)
Do not use this form if a title exists for this vehicle.
Purpose:
Use this form to comply with state and federal laws that require the seller of a motor vehicle to state the odometer mileage upon transfer
of ownership.
Instructions:
Print or Type - Failure to complete or providing false information may result in fines and/or imprisonment. (Sections 409, 412 and 413 of
the Motor Vehicle Information and Cost Savings Act of 1972, Section 46.2-629 of the Code of Virginia.)
VEHICLE INFORMATION
VEHICLE IDENTIFICATION NUMBER
MAKE
BODY TYPE
MODEL
YEAR
SELLER CERTIFICATION
Enter the odometer reading of the vehicle in the box to the right and check one of the following statements.
ODOMETER READING (no tenths)
CHECK ONE BOX ONLY:
Odometer reading entered is THE ACTUAL MILEAGE OF THE VEHICLE
Odometer reading entered is IN EXCESS OF ODOMETER'S MECHANICAL LIMITS
Odometer reading entered IS NOT THE ACTUAL MILEAGE. (WARNING-Odometer Discrepancy)
Vehicle was exempt from disclosure in prior state of title (applicant must present out-of-state title showing exemption)
I certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the
information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand
that knowingly making a false statement or representation on this form is a criminal violation.
SELLER NAME (print)
DATE (mm/dd/yyyy)
SELLER SIGNATURE
SELLER STREET ADDRESS
CITY
STATE
ZIP CODE
BUYER CERTIFICATION
By signing below I acknowledge and certify that I have received a copy of this completed form.
BUYER NAME (print)
BUYER SIGNATURE
DATE (mm/dd/yyyy)
BUYER STREET ADDRESS
CITY
STATE
ZIP CODE