I, _________________________________________________ , certify to the best of my knowledge that the odometer
Seller’s name (type or print)
reading now reads ________________________ (no tenths) miles and reflects the actual mileage of the vehicle described
below, unless one of the following statements is checked:
❏The mileage stated is in excess of its mechanical limits.
❏The odometer reading is not the actual mileage. Warning odometer discrepancy.
Year _______________ Make _____________________ Body Type_________________ Model ____________________
Vehicle Identification Number __________________________________________________________________________
Seller’s Signature ____________________________________________________________________________________
Seller’s Printed Name_________________________________________________________________________________
Seller’s Address _____________________________________________________________________________________
Street
_________________________________________________________________________________________________________
City, State, ZIP
Seller’s Certification Date _____________________________________________________________________________
To be completed by the buyer
Buyer’s Signature ____________________________________________________________________________________
Buyer’s Printed Name ________________________________________________________________________________
Buyer’s Address _____________________________________________________________________________________
Street
_________________________________________________________________________________________________
City, State, ZIP
Buyer’s Acknowledgement Date _________________________________________________________________________
Printed on recycled paper. Printed by authority of the State of Illinois. June 2014 — 45M — VSD 333.3