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ERASURES & ALTERATIONS VOID THIS STATEMENT
STATE OF OHIO
SELLER'S AFFIDAVIT

ODOMETER READING DISCLOSURE STATEMENT

(TYPE OR PRINT IN INK)

NOTICE TO TRANSFEROR: YOU ARE REQUIRED BY LAW TO ENTER ALL INFORMATION REQUIRED HEREIN, INCLUDING THE ODOMETER READING OF THE MOTOR VEHICLE IN THE AFFIDAVIT IMMEDIATELY FOLLOWING.  THE MAKING OF A FALSE STATEMENT UNDER OATH OR AFFIRMATION IS IN VIOLATION OF SECTION 2921.13 OF THE REVISED CODE AND IS PUNISHABLE BY SIX MONTHS IMPRISONMENT AND A FINE OF UP TO ONE THOUSAND DOLLARS, OR BOTH.

STATE OF OHIO,____________________ COUNTY SS: DATE______________ 20____
YEAR _____________ MFR'S SERIAL NO. ___________________________________________
MAKE ______________________________ MODEL _______________________________
BODY TYPE _________________________ MOTOR NO. ___________________________

PURCHASER'S NAME _________________________________________________________
I (we) certify that the mileage registered on this vehicle at the time of assignment is _____________ miles.

CHECK ONE OF THE FOLLOWING STATEMENTS. I (WE) CERTIFY THAT:
To the best of my (our) knowledge, the Odometer reading reflects the actual mileage;
The Odometer reading reflects mileage in excess of the designed mechanical limit of 99,999 miles;
To the best of my (our) knowledge, the Odometer reading is not the actual mileage and should not be relied upon.

CHECK ONE OF THE FOLLOWING. I (WE) CERTIFY THAT, WHILE IN MY (OUR) POSSESSION:
The Odometer of this vehicle was not altered, set back, or disconnected;
The Odometer of this vehicle was repaired or replaced.

X____________________________________________
(Transferor's Signature)                 


Sworn to and subscribed in my presence by______________________________________________
 this day of________________________, 20___.My commission expires_________________, 20___


    SEAL                                ______________________________________
(Clerk, Deputy Clerk of Courts - Notary)    

Trumbull County Clerk of Courts Web Form