How to fill out Mississippi 78-015

The standalone mileage certification for when the certificate cannot carry one - an out-of-state title on its way in, a certificate whose disclosure block is already used, or a transfer where the paperwork needs its own signed statement. One page, one number, two exception statements, and both parties' signatures. The Department's registration checklist asks for exactly this sheet alongside a title from another state.

Top of the blank Mississippi 78-015, Odometer Disclosure Statement, as the agency publishes it

Step 1 · the form itself Blank 78-015 — Odometer Disclosure Statement PDF at dor.ms.gov · new tab View the blank 78-015

Part of our filled-in example of Mississippi 78-015, Odometer Disclosure Statement, showing the filled-in entries

Step 2 · how to fill it in Our filled-in 78-015 guide PDF · 2 pages · 480 KB · new tab See our filled-in example

Two documents, and they are not the same thing. Take the blank 78-015 from the dor.ms.gov copy so you get the revision that is current today, then print our 78-015 guide and keep it beside you while you fill theirs in.

Written against 78-015 (Rev(09/7)), issued under the federal and state mileage-disclosure laws its own banner invokes. The masthead reads Form 78-015-17-8-1-000 Rev(09/7) - the Department's own printing, reproduced here exactly. It is the current copy served from dor.ms.gov's form search, whatever the bracket says.

Last updated August 22, 2026.

Filled in

What a completed one looks like

This is the actual 78-015, rendered from the PDF the Mississippi Department of Revenue, Motor Vehicle Services publishes and completed end to end: letterhead, every field, and the blocks at the foot.

Amber — you write it
Grey — not yours to fill
Numbered — explained below

A Mississippi Form 78-015 odometer disclosure statement filled in: Harmon T. Leflore certifies the odometer of a 2017 Nissan Frontier, VIN 1N6AD0EV8HN760413, reads 87214 miles with neither exception statement checked, signs with his address in Florence, Mississippi and the date 08/12/2026, and transferee Ottis J. Renfroe of Byram signs and prints his name beneath. — The actual 78-015 from dor.ms.gov, completed for the sample sale used across these pages. Neither numbered statement is checked, because leaving them empty is itself the certification that 87214 is the truth - and the transferee's name is written exactly as the title assignment carries it, which the form demands in capitals.

Field by field

Every line, in the order you meet it

1
You fill this in
Your name, into the certification
Your name in the opening blank: I, (name), state that the odometer now reads...
Watch out: Use the name the certificate's face uses. This sheet travels with the title into the same application, and the county matches names across everything it takes.
2
You fill this in
The reading, no tenths
Whole miles off the dashboard, into the box the banner has been warning you about.
Watch out: Read it at handover, not the night before. The figure must agree with the assignment on the certificate exactly - two documents, one number.
3
You fill this in
The two statements - usually neither
Check (1) only for a rolled-over odometer, (2) only when the reading genuinely is not the mileage.
Watch out: Statement (2) prints WARNING - ODOMETER DISCREPANCY for a reason: it follows the vehicle onto its next title and every one after.
4
You fill this in
The vehicle band
Make, model, body type, VIN and year, copied from the certificate.
Watch out: Copy the VIN from the title rather than the door jamb - if the two disagree you have a bigger problem than mileage, and better to find it now.
5
You fill this in
Sign, print, address, date
Transferor's signature and printed name, your street, city or town, state and ZIP, and the date of statement.
Watch out: The date of statement should be the date of sale. A mileage certified days before handover invites the question of who drove the gap.
6
The buyer fills this in
The transferee's half
The buyer signs, prints their name, enters it again exactly as it appears on the title assignment, and adds their address.
Watch out: That as-it-appears instruction is the form doing the county's cross-checking in advance - make the buyer bring the certificate over and copy from it.

At a glance

What goes where

On the form	What to put in it
The warning banner	BOTH FEDERAL LAW AND STATE LAW REQUIRE THAT YOU (THE TRANSFEROR) STATE THE MILEAGE IN CONNECTION WITH THE TRANSFER OF OWNERSHIP - and the banner closes by warning that leaving it incomplete, or making a false statement, can end in fines, imprisonment or both. That sentence is the whole legal architecture of the form.
The certification	I, (name), STATE THAT THE ODOMETER NOW READS (reading) (NO TENTHS) MILES - and that it reflects the actual mileage unless one of the two statements below is checked.
The two exception statements	Statement (1): the reading reflects the amount of mileage in excess of the odometer's mechanical limits - a five-digit odometer that has rolled over. Statement (2): the reading is not the actual mileage, printed with WARNING - ODOMETER DISCREPANCY.
The vehicle	Make, model, body type, vehicle identification number and year, in a boxed band across the middle.
The transferor's block	Your signature, printed name, street, city or town, state and ZIP code, and the date of statement.
The transferee's block	The buyer's signature and printed name, then a line whose instruction deserves reading twice: TRANSFEREE'S NAME - ENTER NAME AS IT APPEARS ON THE ASSIGNMENT OF MGFR'S. CERTIFICATE OF ORIGIN, OR TITLE - then their address.

What gets this one rejected

•Tenths written into the reading. The form says NO TENTHS beside the box; an odometer figure with a decimal in it is the classic way to make five digits read as six.
•A transferee name that does not match the assignment. The form's own capitals instruct that the name be entered as it appears on the certificate of origin or title - a nickname here against a legal name there is a discrepancy on a document about discrepancies.
•Only one signature. The certification is the seller's, but the acknowledgement is the buyer's, and the sheet has a signature line for each because it proves nothing with one.
•Checking statement (2) to be helpful. It brands the vehicle's mileage as not actual on the record, permanently - it is for genuine discrepancies, not for hedging.
•Leaving the date of statement empty. The mileage is a reading at a moment; without the date the number floats free of the sale it certifies.

Rules that decide whether it is accepted

•No exemption line anywhere. Unlike most states' disclosure forms, the 78-015 prints no age or weight exemption and offers no exempt box. The exemptions that exist are federal - 49 CFR 580.17's split at model year 2011 - and on an exempt older car the practical answer is to write the true reading anyway, since the form gives you nowhere to claim anything else.
•It shadows the certificate, not replaces it. Where the certificate's own disclosure block is usable, use it - this sheet exists for the transfers where it is not, and the county will read the two against each other if both exist. They must agree to the mile.

Every line here was read off 78-015 (Rev(09/7)) itself — the PDF is here — and off the Mississippi Department of Revenue, Motor Vehicle Services pages. This is plain-language help with a form, not legal advice, and where our wording and the agency's differ, theirs governs.

Forms that go with this one

Titles from other states are one reason this sheet exists, and our Biloxi page on selling near Keesler Air Force Base notes that an out-of-state title doesn't stop the sale.

Back to all Mississippi seller paperwork, or what selling a car in Mississippi involves.

How to fill out Mississippi 78-015

What a completed one looks like

Every line, in the order you meet it

Your name, into the certification

The reading, no tenths

The two statements - usually neither

The vehicle band

Sign, print, address, date

The transferee's half

What goes where

What gets this one rejected

Rules that decide whether it is accepted

Forms that go with this one

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