Print Form
Clear form
ODOMETER DISCLOSURE STATEMENT
TC-891 Rev. 10/95
Federal and State law require that you state the mileage upon transfer of ownership. Failure to complete, or providing a false statement, may result in fines and/or imprisonment. I, (print name of transferor, or transferor's authorized agent) state that the odometer of the vehicle described below now reads:
ODOMETER READING (NO TENTHS)
Check one box only: I certify that to the best of my knowledge the odometer reading reflects the actual mileage. I certify that to the best of my knowledge the odometer reading reflects the amount of mileage in excess of mechanical limits. I hereby certify that the odometer reading is not the actual mileage. WARNING - ODOMETER DISCREPANCY.
MAKE VEHICLE IDENTIFICATION NUMBER Transferor's or Authorized Agent's Signature (SELLER) Printed Name of Company MODEL BODY TYPE YEAR
Must sign by hand after form is printed.
Transfer's Address (Street) City State ZIP code
DATE OF STATEMENT
Print Form
Transferee's Signature (BUYER) Must sign by hand after form is printed. If an Organization is Transferee, Print Organization's Name Transferee's Address (street) City
Transferee's Printed Name
State
ZIP code
IMPORTANT: To protect your privacy, use the "Clear form" button when you are finished.
Clear form
Print Form