ERASURES AND ALTERATIONS VOID THIS STATEMENT
STATE OF OHIO
APPLICANT'S AFFIDAVIT
ODOMETER READING DISCLOSURE STATEMENT
(TYPE OR PRINT IN INK)

NOTICE TO APPLICANT FOR CERTIFICATE OF TITLE: YOU ARE REQUIRED BY LAW TO ENTER ALL INFORMATION
REQUIRED HEREIN, INCLUDING THE ODOMETER READING OF THIS MOTOR VEHICLE IN THE AFFIDAVIT IMMEDIATELY
FOLLOWING. THE MAKING OF A FALSE STATEMENT UNDER OATH OR AFFIRMATION IS IN VIOLATION OF SECTION 2921.13
OF THE REVISED CODE AND IS PUNISHABLE BY SIX MONTHS IMPRISONMENT AND A FINE OF UP TO ONE THOUSAND
DOLLARS OR BOTH.

	                 STATE OF OHIO,___________________COUNTY SS:DATE______________
	
                    YEAR_________ MFR'S SERIAL NO_________________________________________
     
                    MAKE_________________________MODEL________BODY TYPE___________________

               PURCHASER'S NAME___________________________________________________________

CHECK ONE OF THE FOLLOWING STATEMENTS. I (WE) CERTIFY THAT:

_________ I (We) have made every effort possible and cannot locate the previous owner of the above named motor vehicle
          to obtain the odometer statement required by Section 4505.06 of the Revised Code.

_________ I (We) obtained ownership of the above described motor vehicle by operation of law pursuant to Sections 
          4505.101;4513.60; or 4513.62 of the Revised Code and at the time of transfer of ownership was not able to
          obtain a statement of the odometer reading from the previous owner.

_________ The above described motor vehicle (CHECK ONE) is ___newly self-assembled, __is presently evidenced by a
          salvage certificate of title, or ___was previously regisitered/titled in another state, province, or country
          and    (CHECK ONE OF THE FOLLOWING):
	  ___ To the best of my (our) knowledge, the odometer reading reflects the actual mileage
          ___ The odometer reading reflects mileage in excess of the mechanical limit
          ___ To the best of my (our) knowledge, the odometer reading is not the actual mileage
                     and should not be relied upon

I (we) certify that the mileage registered on the odometer of this motor vehicle at the time of
application for title is ___________________ miles.
                                      (must be completed)

                                                                     ____________________________________________
                                                                     APPLICANT'S SIGNATURE

                        Sworn to and subscribed in my presence by________________________

                        this____ day of _______________________. My commission expires________________ 			   		


                                   SEAL                          ________________________________________________
                                                                 (CLERK, DEPUTY CLERK OF COURTS - NOTARY)