1. Vehicle Description: Enter the vehicle identification number, year, make, model, and
body type.

PART A: POWER OF ATTORNEY TO DISCLOSE MILEAGE

2. Sellers: Enter the printed name of the sellers.
3. Buyers: Enter the printed full legal name of the buyers.
4. Date: Enter the date Part A was completed.
5. Odometer Reading: Enter the exact reading of the vehicle’s odometer apparatus,
excluding tenths.
6. Check the appropriate box if the odometer reading is not the actual mileage of the
vehicle.
7. Enter the signature and printed name of the transferor/seller.
8. Enter the address of the transferor/seller.
9. Enter the signature and printed full legal name of the transferee/buyer

10. Enter the dealer’s business name, if applicable.

11. Enter the business license number of the dealer, if applicable.
12. Enter the address of the transferee/buyer.

PART B: POWER OF ATTORNEY TO REVIEW TITLE DOCUMENT AND ACKNOWLEDGE
DISCLOSURE
Note: Part B is invalid unless Part A has been completed.

13. Enter the printed full legal name of the transferee/buyer.
14. Enter the printed name of the transferor/seller.
15. Enter the signature and printed full legal name of the transferee.
16. Enter the complete address of the transferee.
17. Enter the date Part B was completed.
18. Enter the seller’s printed name.
19. Enter the exact reading of the vehicle’s odometer apparatus, excluding
tenths.
20. Check the appropriate box if the odometer reading is not the actual mileage
of the vehicle.
21. Enter the signature and printed name of the transferor/seller.
22. Enter the dealer’s business name.
23. Enter the business license number of the dealer.
24. Enter the complete address of the transferor/seller.

PART C: CERTIFICATION

Note: Part C is to be completed only if Parts A and B have been completed.
25. Enter the full legal name of the person exercising the power of attorney.
26. Enter the signature and printed name of the person exercising the power of
attorney.
27. Enter the date Part C was completed.
28. Enter the complete address of the person exercising the power of attorney.

Filing and Retention of Copies

• The original copy of the Secure Power of Attorney must be attached to the Certificate of
Title when received and is to remain with the title until the seller making application for title
for the buyer files it.
• The seller must retain the first copy of the Secure Power of Attorney for at least five
years.
• The second copy of the Secure Power of Attorney must be given to the seller who
completed the power of attorney in PART A.