Form Tc 96 4 – Fill Out and Use This PDF

Kentucky Transportation Cabinet	TC 96‐4
Division of Motor Vehicle Licensing	02/2014

ODOMETER DISCLOSURE STATEMENT

(Leased Vehicle)

Attach this form to your Title and Registration application documents and forward to your County Clerk.

NOTE: Federal Law requires that the lease disclose the mileage to the lessor in connection with the transfer of ownership. Failure to complete or making a false statement may result in fines and/or imprisonment. Complete the disclosure form below and return to lessor.

I,		, state that the odometer now reads
	(Print the name of person making disclosure.)		(No tenths)

miles and, to the best of my knowledge, reflects the actual mileage of the vehicle described below unless one of the following

statements is checked.

I hereby certify to the best of my knowledge that the odometer reading reflects mileage in excess of its mechanical limits.

I hereby certify that the odometer reading is NOT the actual mileage.

Make

Model

Body Type

Vehicle Identification #

Year

Lessee’s Name

Address

City

State

Zip

Lessee’s Signature ________________________________________ Date of Statement _____________________

Lessor’s Name

Address

City

State

Zip

Date Disclosure Form Sent to Lessee

Date Completed Disclosure Form Returned from Lessee

Lessor’s Signature ________________________________________ Date of Statement _____________________