: Federal regulations require this statement to be given to purchasers on sales of vehicles. An inaccurate or untrue statement may make you liable for damages to the buyer and there may also be civil or criminal penalties.
CIN, state that the odometer described below now reads 23,145 kilometers.
Certify one of the following-- please'_______' the appropriate line before the correct statement:
_______ I (we) certify that to the best of my (our) knowledge the odometer reading as stated above reflects the actual mileage of the vehicle described below.
_______ I (we) certify that to the best of my (our) knowledge the odometer reading as stated above reflects the amount of mileage in excess of designed mechanical limits of 99,999 kilometers of the vehicle described below.
_______ I (we) certify that to the best of my (our) knowledge the odometer reading as stated above is NOT the actual mileage of the vehicle described below, and should not be relied upon.
MAKE: _______
MODEL: _______
BODY TYPE: four door
YEAR: _______
VEHICLE IDENTIFICATION NUMBER: _______
Certify one of the following please ' _______' the appropriate line before the correct statement:
_______ I (we) certify that the odometer of the vehicle described above was not altered, set back, or disconnected while in my (our) possession, and I (we) have no knowledge of anyone else doing so.
_______ I (we) certify that the odometer was alerted for repair or replacement purposes while in my (our) possession, and that the mileage registered on the repaired or replaced odometer is identical to that before such service.
_______ I (we) certify that if the repaired or replacement odometer was incapable of registering the same mileage, that it was reset to zero, and that the mileage on the original odometer or the odometer before repair was _______ kilometers.
SELLER (Transferor) address:
Main street number 12
44129
Date of statement: _____________________
____________________________________
CIN
BUYER (Transferee) name and address:
COSTCO
Main Street 129-2
45130
Receipt of copy acknowledged:
_______________________________________
COSTCO
______________
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