Form T-107A "Odometer Discrepancy Affidavit" - Georgia (United States)

What Is Form T-107A?

This is a legal form that was released by the Georgia Department of Revenue - a government authority operating within Georgia (United States). As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2005;
  • The latest edition provided by the Georgia Department of Revenue;
  • 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 T-107A by clicking the link below or browse more documents and templates provided by the Georgia Department of Revenue.

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Download Form T-107A "Odometer Discrepancy Affidavit" - Georgia (United States)

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T-107A (Revised 08-2005)
Odometer Discrepancy
Affidavit
Purchaser’s Statement of Facts:
This is to certify that on ___________, I_______________________________________
(Date)
(Purchaser’s Full Legal Name)
________________________________________________________________________
(Purchaser’s Address Including City, State & Zip)
acquired the following vehicle:
__________________________________
__________________________________
(Year & Make Vehicle)
(Vehicle Identification Number)
From:
________________________________________________________________________
(Seller’s Full Legal Name & Address)
This is to also certify that at the time that I acquired this vehicle, the odometer reading on
this vehicle was: _______________________________ and to the best of my knowledge
(Odometer Reading –No Tenths)
reflected the correct odometer reading.
In error, the documents pertaining to the
application for title to this vehicle reflected an incorrect odometer reading due to the
following reason:
________________________________________________________________________
________________________________________________________________________
This is to further certify that I am aware of the facts contained in the above Purchaser’s
Statement of Facts. I further agree to indemnify the Georgia Department of Revenue for
any and all losses, which it might suffer due to the existence of facts to the contrary of
those contained in this affidavit:
_________________________________
_________________________________
(Date)
(Purchaser’s Signature)
Sworn to and subscribed before me this
_________________________________
(Purchaser’s Signature)
________ of ______________, _______
(Day)
(Month)
(Year)
_______________________________________
(Telephone Number Including Area Code)
________________________________
_
(Signature of Notary Public/Justice of Peace)
_______________________________________
(Date Notary Commission Expires)
Important Notice: Affidavits must be obtained from all owners involved since the
discrepancy in the odometer reading occurred. Persons appointed by a power of attorney
cannot complete this affidavit.
Print this form!
Clear form
T-107A (Revised 08-2005)
Odometer Discrepancy
Affidavit
Purchaser’s Statement of Facts:
This is to certify that on ___________, I_______________________________________
(Date)
(Purchaser’s Full Legal Name)
________________________________________________________________________
(Purchaser’s Address Including City, State & Zip)
acquired the following vehicle:
__________________________________
__________________________________
(Year & Make Vehicle)
(Vehicle Identification Number)
From:
________________________________________________________________________
(Seller’s Full Legal Name & Address)
This is to also certify that at the time that I acquired this vehicle, the odometer reading on
this vehicle was: _______________________________ and to the best of my knowledge
(Odometer Reading –No Tenths)
reflected the correct odometer reading.
In error, the documents pertaining to the
application for title to this vehicle reflected an incorrect odometer reading due to the
following reason:
________________________________________________________________________
________________________________________________________________________
This is to further certify that I am aware of the facts contained in the above Purchaser’s
Statement of Facts. I further agree to indemnify the Georgia Department of Revenue for
any and all losses, which it might suffer due to the existence of facts to the contrary of
those contained in this affidavit:
_________________________________
_________________________________
(Date)
(Purchaser’s Signature)
Sworn to and subscribed before me this
_________________________________
(Purchaser’s Signature)
________ of ______________, _______
(Day)
(Month)
(Year)
_______________________________________
(Telephone Number Including Area Code)
________________________________
_
(Signature of Notary Public/Justice of Peace)
_______________________________________
(Date Notary Commission Expires)
Important Notice: Affidavits must be obtained from all owners involved since the
discrepancy in the odometer reading occurred. Persons appointed by a power of attorney
cannot complete this affidavit.
Print this form!
Clear form