"Odometer Disclosure Statement Form" - Wisconsin

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Download "Odometer Disclosure Statement Form" - Wisconsin

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Wisconsin Odometer Disclosure
Statement
Federal and State law requires 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.
I, ______________________ , certify to the best of my knowledge that the odometer
reading is:
❏ The actual mileage of the vehicle to the best of my knowledge;
❏ In excess of its mechanical limits;
❏ Not the actual mileage. ​ W arning - odometer discrepancy.
Mileage at the time of sale is ________________________________.
_____________________
_____________________
_____________________
M ake
Body
Year
_________________________________
_________________________________
M odel
VIN
_________________________________
_________________________________
Last Plate State
Last Plate Number
The Buyer and Seller acknowledge that the motor vehicle is being sold without any
representations ("as-is").
Buyer's Name __________________ Buyer's Signature _______________________
Buyer's Address _______________________________________________________
Seller's Name __________________ Seller's Signature ________________________
Seller's Address ________________________________________________________
First Witness Signature __________________________
First Witness Printed Name _______________________
Second Witness Signature ________________________
Second Witness Printed Name _____________________
Wisconsin Odometer Disclosure
Statement
Federal and State law requires 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.
I, ______________________ , certify to the best of my knowledge that the odometer
reading is:
❏ The actual mileage of the vehicle to the best of my knowledge;
❏ In excess of its mechanical limits;
❏ Not the actual mileage. ​ W arning - odometer discrepancy.
Mileage at the time of sale is ________________________________.
_____________________
_____________________
_____________________
M ake
Body
Year
_________________________________
_________________________________
M odel
VIN
_________________________________
_________________________________
Last Plate State
Last Plate Number
The Buyer and Seller acknowledge that the motor vehicle is being sold without any
representations ("as-is").
Buyer's Name __________________ Buyer's Signature _______________________
Buyer's Address _______________________________________________________
Seller's Name __________________ Seller's Signature ________________________
Seller's Address ________________________________________________________
First Witness Signature __________________________
First Witness Printed Name _______________________
Second Witness Signature ________________________
Second Witness Printed Name _____________________