Free 43230.pdf - Indiana

ODOMETER DISCLOSURE STATEMENT
State Form 43230 (R / 2-97)

ODOMETER DISCLOSURE STATEMENT
State Form 43230 (R / 2-97)

STATE OF INDIANA BUREAU OF MOTOR VEHICLES We, the undersigned, swear of affirm that the information entered on this form is correct. We understand that a false statement may constitute the crime of perjury. Federal and State law requires that you state the mileage upon transfer of ownership. Failure to complete or providing a false statement may result in fines, imprisonment, or both. I, __________________________________ residing at ______________________________
PRINTED NAME OF SELLER(S)

STATE OF INDIANA BUREAU OF MOTOR VEHICLES We, the undersigned, swear of affirm that the information entered on this form is correct. We understand that a false statement may constitute the crime of perjury. Federal and State law requires that you state the mileage upon transfer of ownership. Failure to complete or providing a false statement may result in fines, imprisonment, or both. I, __________________________________ residing at ______________________________
PRINTED NAME OF SELLER(S)

_____________________________________________ certify to the best of my knowledge
ADDRESS OF SELLER

_____________________________________________ certify to the best of my knowledge
ADDRESS OF SELLER

that the odometer reading is the actual mileage of the vehicle described below unless one of the following statements is checked: 1. I hereby certify that to the best of my knowledge the odometer reading Miles (no tenths) reflects the amount of mileage in excess of its mechanical limits. 2. I hereby certify that the odometer reading is NOT the actual mileage. WARNING - ODOMETER DISCREPANCY.
Vehicle make Vehicle year

that the odometer reading is the actual mileage of the vehicle described below unless one of the following statements is checked: 1. I hereby certify that to the best of my knowledge the odometer reading Miles (no tenths) reflects the amount of mileage in excess of its mechanical limits. 2. I hereby certify that the odometer reading is NOT the actual mileage. WARNING - ODOMETER DISCREPANCY.
Vehicle make Vehicle year

Vehicle identification number (VIN)

Vehicle identification number (VIN)

I will not hold the Commissioner of the Bureau of Motor Vehicles, employees of the Bureau of Motor Vehicles, License Branches or their employees in the State of Indiana responsible for any discrepancy shown on the odometer reading.
Signature of seller(s) Date

I will not hold the Commissioner of the Bureau of Motor Vehicles, employees of the Bureau of Motor Vehicles, License Branches or their employees in the State of Indiana responsible for any discrepancy shown on the odometer reading.
Signature of seller(s) Date

PURCHASER'S INFORMATION I am aware of the above odometer certification made by the seller(s).
Name of purchaser(s) Signature of purchaser(s)

PURCHASER'S INFORMATION I am aware of the above odometer certification made by the seller(s).
Name of purchaser(s) Signature of purchaser(s)

Address of purchaser

Address of purchaser