Disclosure Worksheet

All items marked with a * are required for your request to be submitted.

Customer Information

Vehicle Information

Body
(Please describe any damage or defects)

Description Condition Severity of Damage

* Tires
(Check one for each Row)

Description Condition of Tread Age of Tires
Left Front
Right Front
Left Rear
Right Rear
Spare

Tires
(Check one for each Row)

Description Condition of Tread
Left Front
Right Front
Left Rear
Right Rear
Spare
Description Age of Tires
Left Front
Right Front
Left Rear
Right Rear
Spare

* Customer Disclosure

I certify to the best of my knowledge, this vehicle (check one in each line)

been wrecked, damaged, or destroyed. IF "Has" been, Approximate Damage Amount $

had air bags deployed.

salvage history, rebuilt salvage, or branded title.

Canadian History

Federal and State law require that you state the mileage of the vehicle described on this certificate when transferring ownership. Failure to do so, or providing a false statement, may result in fines and/or imprisonment.

I certify that, to the best of my knowledge, this odometer reading reflects the "ACTUAL MILEAGE" of the vehicle described above.

I certify that, to the best of my knowledge, this odometer reading "EXCEEDS MECHANICAL LIMITS".

I certify that, to the best of my knowledge, this odometer reading is "NOT THE ACTUAL MILEAGE" WARNING ODOMETER DISCREPANCY.