Warning: This form may be used only when title is physically held by lienholder or has been lost. This form must be submitted to the state by the person exercising powers of attorney. Failure to do so may result in fines and/or imprisonment.

VEHICLE DESCRIPTION

Year ____ Make _______

Model _______ Body Type _______

Vehicle Identification Number ____________

Part A. Power of Attorney To Disclose Mileage

Federal law (and State Law, if applicable) requires that you state the mileage upon transfer of ownership. Providing a false statement may result in fines and/or imprisonment.

I, _______________ (transferor's name, Print) appoint _______________ (transferee's name, Print) as my attorney-in-fact, to disclose the mileage, on the title for the vehicle described above, exactly as stated in my following disclosure.

I state that the odometer now reads ______ (no tenths) miles and to the best of my knowledge that it reflects the actual mileage unless one of the following statements is checked.

__ (1) I hereby certify that to the best of my knowledge the odometer reading reflect the mileage in excess of its mechanical limits.

__ (2) I hereby certify that the odometer reading is NOT the actual mileage. WARNING—ODOMETER DISCREPANCY.

(Transferor's Signature)

(Printed Name)

Transferor's Address (Street) ____________

(City) ______ (State) __ (ZIP Code) _____.

Date of Statement ________

(Transferee's Signature)

(Printed Name)

Transferee's Name ____________

Transferee's Address (Street) ____________

(City) ______ (State) __ (ZIP Code) _____.

Part B. Power of Attorney To Review Title Documents and Acknowledge Disclosure.

(Part B is invalid unless Part A has been completed.)

I, _______________ (transferee's name, Print) appoint _______________ (transferor's name, Print) as my attorney-in-fact, to sign the mileage disclosure, on the title for the vehicle described above, only if the disclosure is exactly as the disclosure completed below.

(Transferee's Signature)

(Printed Name)

Transferee's Name ____________

Transferee's Address (Street) ____________

(City) ______ (State) __ (ZIP Code) _____.

Federal law (and State Law, if applicable) requires that you state the mileage upon transfer of ownership. Providing a false statement may result in fines and/or imprisonment.

I, __________ (transferor's name, Print) state that the odometer now reads ______ (no tenths) miles and to the best of my knowledge that it reflects the actual mileage unless one of the following statements is checked.

__ (1) I hereby certify that to the best of my knowledge the odometer reading reflect the mileage in excess of its mechanical limits.

__ (2) I hereby certify that the odometer reading is NOT the actual mileage. WARNING—ODOMETER DISCREPANCY.

(Transferor's Signature)

(Printed Name)

Transferor's Address (Street) ____________

(City) ______ (State) __ (ZIP Code) _____.

Date of Statement ________

Part C. Certification

(To Be Completed When parts A and B Have Been Used)

I, ________, (person exercising above powers of attorney, Print), hereby certify that the mileage I have disclosed on the title document is consistent with that provided to me in the above power of attorney. Further, upon examination of the title and any reassignment documents for the vehicle described above, the mileage diclosure I have made on the title pursuant to the power of attorney is greater than that previously stated on the title and reassignment documents. This certification is not intended to create, nor does it create any new or additional liability under Federal or State law.

(Signature)

(Printed Name)

Address (Street)

(City) ________ (State) __ (ZIP Code) _____

Date ________

[54 FR 9816, Mar. 8, 1989, as amended at 54 FR 35889, Aug. 30, 1989]