Odometer Disclosure Affidavit

Southern Speedometer — 3910 West Alva Street, Tampa, FL 33614

727-341-1222

Vehicle Information

Year

Make

Model

VIN

Current Mileage

Date

Reason for Altering / Transferring Mileage

Check all that apply:

Odometer replacementSpeedometer replacementInstrument cluster replacementOdometer repair / restorationMileage transfer to replacement unitInaccurate / erratic odometer readingElectrical malfunction / damageTotal loss / salvage vehicle rebuildCluster upgrade / conversion

Other (specify)

Owner Information

Full Name

Phone

Address

Certification

I hereby certify that the information provided above is true and accurate to the best of my knowledge. I understand that odometer disclosure is required by federal law (49 U.S.C. §32705) and that providing false information may result in penalties.

Owner Signature

Date Signed

For Shop Use Only

Technician Signature

Notary / Witness (Optional)