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.
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.
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.
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
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.
