Section 1 - Transaction Information
Date of Disclosure: [[Date of Disclosure]]
Vehicle Identification Number (VIN): [[Vehicle Identification Number]]
Year / Make / Model / Trim: [[Vehicle Year]] [[Vehicle Make]] [[Vehicle Model]] [[Vehicle Trim]]
Current Odometer Reading: [[Current Odometer Reading]] miles
Seller Name: [[Seller Full Legal Name]]
Seller Address: [[Seller Street Address]], [[Seller City]], CT [[Seller ZIP]]
Buyer Name: [[Buyer Full Legal Name]]
Buyer Address: [[Buyer Street Address]], [[Buyer City]], [[Buyer State]] [[Buyer ZIP]]
Section 2 - Title and Brand Disclosure
- Is the title to this vehicle branded as salvage, rebuilt, reconstructed, flood-damaged, lemon-law buyback, or similar?
[ ] No
[ ] Yes - Brand type: [[Brand Type - e.g. Salvage, Rebuilt, Flood]]
Explanation / history: [[Full explanation of title brand history and repairs]]
- Has the vehicle ever been declared a total loss by an insurance company?
[ ] No
[ ] Yes - Details and date: [[Date and insurance company details]]
- Has the vehicle sustained significant damage from flood, fire, hail, or collision that required structural or major mechanical repairs?
[ ] No
[ ] Yes - Describe repairs and date: [[Description]]
- Are there any open safety recalls on this vehicle that have not been completed?
[ ] No
[ ] Yes - Recall campaign number(s) and status: [[Recall details]]
- Is the vehicle currently subject to a lien or security interest that will not be released at or before closing?
[ ] No
[ ] Yes - Lienholder: [[Lienholder Name and payoff instructions]]
Section 3 - Known Defects and Condition Disclosure
The seller discloses the following known defects, damage, or conditions (list all that apply; if none, state "None known"):
- Engine / Drivetrain issues: [[Describe any known problems or state "None known"]]
- Transmission / Clutch problems: [[Describe or "None known"]]
- Brake system condition: [[Describe or "None known"]]
- Suspension / Steering issues: [[Describe or "None known"]]
- Electrical / Computer / Sensor faults: [[Describe or "None known"]]
- Body / Frame / Rust / Accident damage history: [[Describe or "None known"]]
- Interior / Upholstery / Equipment problems: [[Describe or "None known"]]
- Tire / Wheel condition (including spare): [[Describe tread depth, age, or issues]]
- Air conditioning / Heating / Defrost: [[Status]]
- Any other material facts that a reasonable buyer would consider important in deciding whether to purchase: [[Other disclosures or "None"]]
Section 4 - Odometer and Usage Disclosure
Odometer Statement (attach federal form if transferring title):
The odometer reading listed in Section 1 is:
- The actual mileage of the vehicle to the best of seller's knowledge.
- Exceeds the mechanical limits of the odometer (over 999,999 miles).
- Is not the actual mileage - discrepancy exists (explain): [[Explanation]]
Usage / Service History Notes:
- The vehicle has been used primarily as: [[Personal / Commercial / Fleet / Taxi / Rental / Other]]
- Maintenance records available? [ ] Yes [ ] No - Location: [[Records location]]
- Any aftermarket modifications or performance alterations: [[Describe or "None"]]
Section 5 - As-Is Acknowledgment and Warranty Disclaimer
IMPORTANT - READ BEFORE SIGNING
The vehicle described above is sold AS IS and WHERE IS, with all faults. The seller makes no representations or warranties, express or implied, concerning the vehicle's condition, merchantability, fitness for a particular purpose, or any other matter, except as expressly stated in a separate written warranty (if any) or required by law.
The buyer acknowledges that:
- The buyer has had the opportunity to inspect the vehicle or has chosen to purchase without inspection.
- The buyer is relying solely on the buyer's own inspection and the disclosures contained in this document.
- The seller has disclosed all known material defects as listed above.
- This disclosure is incorporated into any bill of sale or purchase agreement for this vehicle.
Buyer understands that Connecticut law and federal law provide certain non-waivable protections; this form does not limit those rights.
Section 6 - Signatures and Acknowledgments
SELLER CERTIFICATION
I certify under penalty of perjury that the information provided in this disclosure is true and complete to the best of my knowledge.
Seller Signature: ____________________________ Date: [[Date]]
Printed Name: [[Seller Full Legal Name]]
BUYER ACKNOWLEDGMENT
I have read and understand this disclosure. I accept the vehicle in its disclosed condition.
Buyer Signature: ____________________________ Date: [[Date]]
Printed Name: [[Buyer Full Legal Name]]
WITNESS (optional but recommended for private sales)
Witness Signature: ____________________________ Date: [[Date]]
Printed Name: [[Witness Full Name]]
> ⚠️ Template example - not professional (legal/financial/medical) advice. This disclosure is a general template. Verify all statements against current Connecticut law and federal requirements before use. Sellers must disclose known defects truthfully; nondisclosure may result in liability under CUTPA and other laws. Attach the federal odometer disclosure when required for title transfer. Consult a licensed Connecticut attorney for complex transactions or disputes. Sources verified as of June 2026: Conn. Gen. Stat. Title 14 (Motor Vehicles), Title 42a (UCC), § 42-110a et seq. (CUTPA); 49 U.S.C. § 32705; 49 C.F.R. Part 580; 16 C.F.R. Part 455 (FTC Used Car Rule); Connecticut DMV forms and guidance.
