STATE OF OHIO – APPLICANT’S AFFIDAVIT – ODOMETER READING DISCLOSURE STATEMENT (Fillable)

STATE OF OHIO, blank for county.

DATE.

YEAR.

MFR’S SERIAL NO.

MAKE.

MODEL.

BODY TYPE.

PURCHASER’S NAME.

Mileage registered on the odometer at the time of application for title, in miles.

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

The above described motor vehicle (CHECK ONE) is newly self-assembled, is presently evidenced by a salvage certificate of title, or was previously registered/titled in another state, province, or country.

(CHECK ONE OF THE FOLLOWING): To the best of my (our) knowledge, the odometer reading reflects the actual mileage; reflects mileage in excess of the designed mechanical limit of 99,999 miles; or is not the actual mileage and should not be relied upon.

ERASURES & 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 THE 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, blank for county.

DATE.

YEAR.

MFR’S SERIAL NO.

MAKE.

MODEL.

BODY TYPE.

PURCHASER’S NAME.

Mileage registered on the odometer at the time of application for title, in miles.

I (we) have made every effort possible and cannot locate the previous owner of the above described 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 Section 4505.10; 4505.101; 4513.60; 4513.61 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 is newly self-assembled, is presently evidenced by a salvage certificate of title, or was previously registered/titled in another state, province, or country.

newly self-assembled

presently evidenced by a salvage certificate of title

previously registered/titled in another state, province, or country

To the best of my (our) knowledge, the odometer reading reflects the actual mileage

The odometer reading reflects mileage in excess of the designed mechanical limit of 99,999 miles

To the best of my (our) knowledge, the odometer reading is not the actual mileage and should not be relied upon