Form Rv F1317001 – Fill Out and Use This PDF

PURPOSE: Federal and state law require both seller (transferor) and buyer (transferee) to accurately state the mileage of any used motor vehicle, with a manufacture year of 2011 or newer, in connection with the transfer of ownership whether sale, trade-in or exchange. Failure to complete or providing a false statement may result in fines and/or imprisonment.

INSTRUCTIONS: In Section A, the seller (transferor) prints their name on the line and checks one box that best applies. In Section B, the seller (transferor) and/or buyer (transferee) complete the required information, including the date of transaction.

SECTION A:

I,

SELLER OR TRANSFEROR'S NAME (PLEASE PRINT)

Certify to the best of my knowledge that the odometer reading on the vehicle described below is one of the following statements (check one):

2.In Excess of Mechanical Limits: I hereby certify that the mileage stated is in excess of the mechanical limits of the odometer (check only if digits on odometer are impossible to determine).

3.Not Actual Mileage - odometer reading is not the actual mileage. WARNING - Odometer Discrepancy form must be completed, or titling transaction will be delayed.

EXEMPTIONS, as defined by NHTSA (National Highway Traffic Safety Administration), "a transfer of any of the following motor vehicles need not disclose the vehicle's odometer mileage under the following circumstances:

a)Gross Vehicle Weight Rating of more than 16,000 pounds

b)Vehicle not self-propelled

c)Vehicle is model year 2010 or older

d)Vehicle sold directly by the manufacturer to any agency of the United States in conformity with contractual specifications

e)New vehicle prior to first transfer for purposes other than resale

Buyer Name (Print):_________________________________ Buyer Signature:_______________________________ Date:_____________

Any alterations or corrections may void this form.