A separate mileage certification, printed four times over on one sheet so a vehicle can pass through several hands on the same document. It exists for the transfers where the title itself cannot carry the disclosure - and the form's own instructions rule most Missouri sellers out of needing it, which is the most useful thing on the page.
Written against Form 3019 (Rev 01-2021), issued under RSMo 407.536 and 49 CFR Part 580.
Read the reverse before you fill in the front. For a Missouri title issued at any time in the last thirty-odd years the mileage belongs on the assignment, and a separate 3019 is the answer to a different question - a title from a state whose form does not meet the federal requirement, or a transfer where the certificate itself cannot carry the disclosure.
Two documents, and they are not the same thing. Take the blank Form 3019 from the dor.mo.gov copy so you get the revision that is current today.
This is the actual Form 3019, rendered from the PDF the Missouri Department of Revenue 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 first of four disclosure spaces, completed. Neither tick box is marked, because the printed sentence above them already certifies the reading as actual unless one of them is - and the three empty spaces below are for the people who own this car after the buyer. The two signature rules are left blank on purpose: the Department's PDF has no fillable box behind them, and its own instruction is that everything on this form may be typed except the printed names and the signatures.
Field by field
Every line, in the order you meet it
1
You fill this in
The vehicle, once, at the top
Year, make, vehicle identification number, title number, state, model and body style.
Watch out: This band serves all four disclosure spaces on the sheet, which is why it is outside them. Copy it from the title rather than from the car.
2
You fill this in
Purchaser's name and the date
The buyer's name printed or typed, and the date of the transfer beside it.
Watch out: The date is the day the car changed hands, and it needs to be the same day you wrote on the title assignment and on the notice of sale.
3
You fill this in
Your name, and the dealer number you skip
Seller(s) (firm) name printed or typed, with your address underneath. The DEALER NO. box beside it belongs to licensed dealers.
Watch out: A private seller leaves the dealer number empty. Writing anything in it invites the license office to treat the transfer as a dealer sale, which changes the tax treatment.
4
You fill this in
The odometer reading
The mileage in whole miles, in the block labelled no tenths.
Watch out: Read it off the dash on the day, not from a service invoice. The certification beside it is a statement about now.
5
You fill this in
The two statements
Mileage in excess of its mechanical limits, or Mileage reading not actual. Tick one only if it is true.
Watch out: The Department's own worked example for the first: an actual mileage of 125,000 where only 25,000 shows, so you write 25,000 and tick the box. The second one puts a permanent brand on every title the car is ever issued.
6
You fill this in
Both signatures
Signature of purchaser and signature of seller, side by side, in the first disclosure space.
Watch out: In pen. The instruction is that everything on this form can be typed or computer generated except the printed names and signatures.
7
The buyer fills this in
Both hand printed names
A second pair of rules beneath the signatures.
Watch out: One purchaser and one seller must hand print their name. The Department asks for the printed name on this form for the same reason it asks on the title - a signature is not a name it can read.
At a glance
What goes where
On the form
What to put in it
Vehicle band
Year, make and vehicle identification number across the top, then title number, state, model and body style on the second line. Filled in once, at the head of the sheet.
Purchaser(s) name and date
Printed or typed, with the date of the disclosure beside it. Each of the four disclosure spaces has its own.
Seller(s) (firm) name
Printed or typed, with a dealer number box that a private seller leaves empty.
Odometer reading (no tenths)
The reading, beside the printed certification: I state that the odometer now reads the aforementioned miles and to the best of my knowledge that it reflects the actual mileage of the vehicle described herein, unless one of the following statements is checked.
The two statements
Mileage in excess of its mechanical limits, and Mileage reading not actual (WARNING, ODOMETER DISCREPANCY). Tick boxes to the right of the certification.
Signature of purchaser(s) and Signature of seller(s)
Two signature rules side by side under each disclosure.
Hand printed name(s)
A second pair of rules under the signatures, because Missouri asks for the name printed as well as signed here exactly as it does on the title.
Three further disclosure spaces
The same block repeated down the page and onto the reverse, for the second, third and fourth transfers of the same vehicle.
What gets this one rejected
•Using it when the title should carry the disclosure. The instructions on the reverse are explicit: if the Missouri title was issued after August 28, 1989, the odometer disclosure is required to be completed on the back of the title rather than on a separate disclosure statement.
•Typing the names and signatures. All information on the disclosure statement can be typed or computer generated except for the printed names and signatures of the purchaser(s) and seller(s).
•Tenths of a mile. The block is labelled odometer reading (no tenths), and a decimal is not the figure a license office will key.
•Ticking Mileage reading not actual and stopping there. The seller must also submit a statement explaining all facts concerning the true mileage - which is what Form 1545 is for.
•Scribbling out a spoiled disclosure. The Department's correction procedure is to draw a large X through that disclosure space, use the next one, and attach a signed statement explaining the error.
•A reading that disagrees with the one on the title assignment. The license office reads them side by side.
Rules that decide whether it is accepted
•One purchaser and one seller sign. The instructions say so twice - one purchaser and one seller must sign the form, and one purchaser and one seller must hand print their name. That is a lighter requirement than the title assignment, where every owner on the face signs.
•Four disclosures, then a new sheet. If the error is made while completing the fourth disclosure space, a new odometer disclosure statement is required.
•The exemptions are printed on the back. Model year 2010 or older and at least ten years old at transfer; model year 2011 or newer and at least twenty years old; over 16,000 pounds gross vehicle weight rating; and a new vehicle moving between franchise dealers.
Every line here was read off Form 3019 (Rev 01-2021) itself — the PDF is here — and off the Missouri Department of Revenue pages.
This is plain-language help with a form, not legal advice, and where our wording and the agency's differ,
theirs governs.
