Section 1 - Transfer Information
PENNSYLVANIA ODOMETER DISCLOSURE STATEMENT
Date of Disclosure / Transfer: [[Date of Disclosure]]
SELLER / TRANSFEROR
Name: [[Seller Full Legal Name]]
Address: [[Seller Street Address]], [[Seller City]], PA [[Seller ZIP Code]]
Phone: [[Seller Phone Number]]
BUYER / TRANSFEREE
Name: [[Buyer Full Legal Name]]
Address: [[Buyer Street Address]], [[Buyer City]], [[Buyer State]] [[Buyer ZIP Code]]
Phone: [[Buyer Phone Number]]
Section 2 - Vehicle Identification
| Field | Value |
|---|
| Year | [[Vehicle Year]] |
| Make | [[Vehicle Make]] |
| Model | [[Vehicle Model]] |
| Trim / Body | [[Trim or Body Style]] |
| VIN | [[17-Character Vehicle Identification Number]] |
| Title Number (if known) | [[Title Number]] |
| Current Title State | Pennsylvania |
Section 3 - Odometer Reading and Certification
Odometer Reading at Time of Transfer: [[Odometer Reading]] miles (do not include tenths)
Certification by Seller / Transferor (check only one):
- I certify that to the best of my knowledge the odometer reading stated above reflects the actual mileage of the vehicle described above.
- I certify that to the best of my knowledge the odometer reading stated above reflects the mileage of the vehicle in excess of its mechanical limits (the odometer has turned over or been replaced and is no longer capable of registering the actual mileage).
- I certify that to the best of my knowledge the odometer reading stated above does not reflect the actual mileage of the vehicle described above and is a DISCREPANCY. WARNING - ODOMETER DISCREPANCY.
Seller / Transferor Statement and Signature
I state under penalty of perjury that the information provided on this form is true and correct to the best of my knowledge.
Seller Printed Name: [[Seller Full Legal Name]]
Seller Signature: _______________________________ Date: [[Date]]
Section 4 - Buyer / Transferee Acknowledgment
I, the buyer/transferee, acknowledge that I have received a copy of this odometer disclosure statement and understand its contents.
Buyer Printed Name: [[Buyer Full Legal Name]]
Buyer Signature: _______________________________ Date: [[Date]]
Section 5 - Additional Information and Notes
Odometer Replacement or Repair (if applicable):
If the odometer has been replaced or repaired, the seller must provide the previous reading and the date of replacement if known: Previous reading [[Previous Reading]] on [[Date of Replacement]].
Exempt Vehicle Statement (if applicable):
This vehicle is exempt from odometer disclosure requirements because:
- [ ] It is 10 or more model years old (confirm current federal threshold at time of sale).
- [ ] It is a vehicle with a gross vehicle weight rating over 16,000 pounds.
- [ ] Other exemption per 49 C.F.R. § 580.17: [[Specify]].
Seller initials if claiming exemption: ____
Known Odometer Issues or Inconsistencies:
[[Describe any known issues with the odometer, cluster replacement, or "None known."]]
Section 6 - Federal and Pennsylvania Penalty Warnings
Federal law provides that a person who violates odometer disclosure requirements with intent to defraud may be subject to civil penalties of up to $10,000 per violation and criminal penalties including fines and imprisonment. Pennsylvania enforces these requirements during title processing and may refuse title issuance or pursue additional remedies for non-compliance or fraud.
Buyers should retain this disclosure with the bill of sale and title documents for their records. Sellers should retain a signed copy.
Section 7 - Delivery of Disclosure
This disclosure was provided to the buyer on [[Date Provided]] together with:
- [ ] Title or assignment of title
- [ ] Bill of Sale dated [[Date]]
- [ ] Other documents: [[List]]
Section 8 - Signatures and Notary (Optional)
Seller
Signature: _______________________________
Printed Name: [[Seller Full Legal Name]]
Date: [[Date]]
Buyer
Signature: _______________________________
Printed Name: [[Buyer Full Legal Name]]
Date: [[Date]]
Notary Acknowledgment (Commonwealth of Pennsylvania)
County of [[County]]
On [[Date]], before me personally appeared the seller and buyer named above, who acknowledged executing this disclosure for the purposes stated herein.
Notary Public: _______________________________
Printed Name: [[Notary Name]]
Commission Expires: [[Expiration Date]]
(Seal)
Section 9 - PennDOT Titling Notes
- Attach this completed disclosure to the title application package submitted to PennDOT or an authorized agent.
- For vehicles requiring odometer disclosure, incomplete or missing disclosure will delay or prevent title issuance.
- Confirm the current model-year threshold and exemption criteria with PennDOT at the time of the transaction, as rules are subject to periodic update.
- This template is designed to meet federal minimums and common Pennsylvania practice. Use official PennDOT forms when provided or preferred by the processing office.
> ⚠️ Template - not professional (legal/financial/medical) advice. This disclosure template is for informational purposes. Odometer disclosure requirements are strictly enforced. Always verify current thresholds, forms, and procedures with PennDOT and the National Highway Traffic Safety Administration before use. Sources verified as of June 2026: 49 U.S.C. § 32705; 49 C.F.R. Part 580; PennDOT vehicle title transfer guidance.
End of Pennsylvania Odometer Disclosure
