Free TC-896 - Utah

TC-896 Rev. 6/89 ODOMETER DISCLOSURE STATEMENT Clear form LEASED VEHICLE

Federal and Utah State law require that the lessee disclose the mileage to the lessor in connection with the transfer of ownership. Failure to complete or providing a false statement may result in fines and/or imprisonment. Complete the disclosure below and return to lessor.
Year Model Vehicle Identification Number Make Body Type

I, (print name of person making disclosure) state that the odometer now reads:

ODOMETER READING

(NO TENTHS)

miles and to the best of my knowledge that it reflects the actual mileage of the vehicle described above, unless one of the following statements is checked. (1) I hereby certify that to the best of my knowledge the odometer reading reflects the amount of mileage in excess of its mechanical limits. (2) I hereby certify that the odometer reading is NOT the actual mileage.
Lessee's Name (Print) X Lessee's Signature Lessee's Address Date of Statement Lessor's Name (Print) X Lessor's Signature Lessor's Address Date Disclosure Sent to Lessee City State ZIP Authorized Agent (Print) City State ZIP Authorized Agent (Print)

Date Completed Disclosure Received from Lessee