Home > Legal > Legal > Power of Attorney Template > Kansas Power of Attorney Form > Kansas Power of Attorney, Purchase Price & Odometer Disclosure for Electronic Title Template

Kansas Power of Attorney, Purchase Price & Odometer Disclosure for Electronic Title Form


Kansas Power of Attorney, Purchase Price & Odometer Disclosure for Electronic Title Form
Kansas Power of Attorney, Purchase Price & Odometer Disclosure for Electronic Title Form
KANSAS
DEPARTMENT OF REVENUE
DIVISION OF VEHICLES
www.ksrevenue.org
POWER OF ATTORNEY,
PURCHASE PRICE & ODOMETER DISCLOSURE
FOR ELECTRONIC TITLE
As of January 2003, the Kansas Division of Vehicles will not issue a title of any type when there is a lien for that vehicle
recorded with the division. This power of attorney and odometer disclosure is to be used by the seller to appoint the buyer or
another person to act on their behalf when the State of Kansas holds the title in electronic form.
This form can only be used when a vehicle is sold by the owner to an individual or business that is not a licensed
dealer. This is also known as an isolated or occasional sale.
This form MUST be printed legibly by hand using blue or black ink. Do not type.
VEHICLE INFORMATION
Year Make Style VIN
Federal and Kansas law requires that you state the mileage upon transfer of ownership. Providing a false statement may
result in fines and/or imprisonment.
I, (transferor/seller’s name, print) appoint as my
attorney-in-fact (transferee/buyer’s name, print) , for
the purpose and with full authority to apply for a certificate of title and/or registration upon the vehicle described above, and
further grant the authority to endorse and transfer title thereto, and disclose the mileage to this vehicle exactly as stated in
the following disclosure I have made for the vehicle described above. The date of this statement is .
I, the owner/seller, state that the odometer now reads (no tenths) miles and to the best of my
knowledge that it reflects the actual mileage unless one of the following statements is checked:
(1) I hereby certify that to the best of my knowledge the odometer reading reflects the mileage in excess of
mechanical limits.
(2) I hereby certify that the odometer reading is NOT the actual mileage. WARNING: ODOMETER DISCREPANCY
By my signature, I the seller, swear and affirm the purchase price is $ and is true and accurate under
penalty of perjury. I am aware that the law provides severe penalties for making false statements under oath.
Transferor/ Transferor/Seller’s
Seller’s Signature Hand Printed Name
Transferor/Seller’s Address City State ZIP
I, the buyer, am aware of the odometer certification made by the seller. I further swear and affirm the above stated
purchase price is true and accurate under penalty of perjury. I am aware that the law provides severe penalties for making
false statements under oath.
Transferee/ Transferee/Buyer’s
Buyer’s Signature Hand Printed Name
Transferee/Buyer’s Address City State ZIP
NOTICE TO BUYER: If the vehicle described in this power of attorney and odometer disclosure is not
being titled in the State of Kansas, it is recommended you confirm with your state’s DMV they will
honor this form for vehicles 10 model years old or less.
TR-40www (Rev. 03/05)
Kansas Power of Attorney, Purchase Price & Odometer Disclosure for Electronic Title Form