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3019 - PURCHASER(S NAME DATE(PRINTED OR TYPED ADDRESS...

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Unformatted text preview: PURCHASER(S) NAME DATE (PRINTED OR TYPED) ADDRESS SELLER(S) (FIRM) NAME DEALER NO. (PRINTED OR TYPED) ADDRESS PURCHASER(S) NAME DATE (PRINTED OR TYPED) ADDRESS SELLER(S) (FIRM) NAME DEALER NO. (PRINTED OR TYPED) ADDRESS PURCHASER(S) NAME DATE (PRINTED OR TYPED) ADDRESS SELLER(S) (FIRM) NAME DEALER NO. (PRINTED OR TYPED) ADDRESS PURCHASER(S) NAME DATE (PRINTED OR TYPED) ADDRESS SELLER(S) (FIRM) NAME DEALER NO. (PRINTED OR TYPED) ADDRESS MISSOURI DEPARTMENT OF REVENUE MOTOR VEHICLE BUREAU ODOMETER DISCLOSURE STATEMENT MO 860-2086 (11-2005) DISTRIBUTION: WHITE —ATTACH TO MSO OR CERT. OF TITLE FORM 3019 (REV. 11-2005) Federal law (and State law, if applicable) requires that you state the mileage upon transfer of ownership. Failing to complete or providing a false statement may result in fines and/or imprisonment. INSTRUCTIONS ON REVERSE YEAR MAKE VEHICLE IDENTIFICATION NUMBER TITLE NUMBER STATE MODEL BODY STYLE If purchaser/seller is an agent/officer of a firm, record official position after printed name. The purchaser/seller should retain a copy of this odometer disclosure statement. If “Warning, Odometer Discrepancy” is checked, the seller must attach a statement explaining all facts regarding the discrepancy. ODOMETER READING (NO TENTHS) I state that the odometer now reads the aforementioned miles and to the best of my knowledge that it reflects the actual mileage of the vehicle described herein, unless one of the following statements is checked.described herein, unless one of the following statements is checked....
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3019 - PURCHASER(S NAME DATE(PRINTED OR TYPED ADDRESS...

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