Home | Mercedes-Benz Financial Services

84-001-1139 (5/12)

ODOMETER DISCLOSURE STATEMENT

Federal law (and State law, if applicable) requires that you state the mileage upon transfer of ownership. Failure to complete or making a false statement may result in fines and/or imprisonment.

Complete disclosure form below and return to lessor.

I, __________________________________________________________________ (lessee's name, Print) state that the odometer now reads ________________ (no tenths).

Check ONE item only:

(1) I hereby certify that to the best of my knowledge the odometer reading as stated above reflects the actual mileage of the vehicle described below.

(2) I hereby certify that to the best of my knowledge the odometer reading reflects the amount of mileage in excess of its mechanical limits.

(3) I hereby certify that the odometer reading is NOT the actual mileage. WARNING: ODOMETER DISCREPANCY.

YEAR

MAKE

MODEL

BODY TYPE

VEHICLE IDENTIFICATION NUMBER

ACCOUNT NO.

LESSEE'S NAME AND ADDRESS

DATE OF STATEMENT (CURRENT DATE) LESSEE'S SIGNATURE

X CO-LESSEE'S NAME AND ADDRESS

DATE OF STATEMENT (CURRENT DATE) CO-LESSEE'S SIGNATURE

X LESSOR'S NAME AND ADDRESS

DATE DISCLOSURE FORM SENT TO LESSEE LESSOR'S SIGNATURE

X

DATE COMPLETED DISCLOSURE FORM RECEIVED FROM LESSEE

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download