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Motor Vehicle Administration 6601 Ritchie Highway N.E. Glen Burnie Maryland 21062 VR-197 04-10 Odometer Disclosure Statement Federal and State law requir es that you state the mileage in connection with the transfer of ownership. Failure to complete or providing a false statement may result in fines and/or imprisonment. Warning - odometer discrepancy Make Model Body Type Year Vehicle Identification No. Seller s Signature Seller s Printed Name Seller s Street Address City State Zip Code Date...

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Provide the relevant details about the incident or event that the form is being filled for.

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This form may be needed by individuals who need to report an incident to their insurance company.

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