*FAX 251- 665 - 6838
MANUAL ODOMETER DISCLOSURE STATEMENT, DISPOSITION FEE WAIVER, AND
VEHICLE TURN-IN ACKNOWLEDGEMENT FORM
Odometer Reading: (no tenths)
YEAR:
MAKE:
Current Vehicle Identification Number:
MODEL:
MMCA Account Number: (Leases start with 85 or 86)
Federal law (and State law, if applicable) requires that you state the mileage upon transfer of ownership. Failure to complete or
providing a false statement may result in fines and/or imprisonment. I, the undersigned Customer, certify under penalty of perjury
that the odometer now reads as marked above and to the best of my knowledge it reflects the actual mileage of the vehicle
described above, unless one of the following statements is marked:
WARNING: Odometer Discrepancy:
LESSEE’S NAME:
1) _____ The odometer reading is not the actual mileage.
2) _____ The mileage exceeds the odometer mechanical limits.
CUSTOMER ACKNOWLEDGEMENT
LESSEE’S SIGNATURE
X
LESSEE’S ADDRESS:
DATE OF STATEMENT:
,
DISPOSITION FEE WAIVER (If applicable)
The following conditions must be met for an existing customer to qualify for waiver of the disposition fee.
1)
2)
The customer must lease or finance the purchase of a qualifying new Mitsubishi vehicle.
The new contract must be approved and assigned to MMCA.
Did customer lease/ finance the new Mitsubishi with MMCA? YES_____ NO _____
New Vehicle Identification Number:
RETAILER ACKNOWLEDGEMENT
DEALERSHIP NAME & DEALER CODE:
NAME of REPRESENTATIVE ACCEPTING VEHICLE:
ADDRESS:
TITLE:
LESSOR ACKNOWLEDGEMENT
LESSOR NAME:
MITSUBISHI MOTORS CREDIT OF AMERICA,
Administrator for MMCA Lease Ltd
ADDRESS:
6400 KATELLA AVE, CYPRESS, CA 90630
LESSOR SIGNATURE: (MMCA REPRESENTATIVE):
X
TITLE:
DATE RECEIVED BY LESSOR:
ALL FIELDS MUST BE COMPLETED OR ODOMETER IS INVALID