How to fill out Virginia VSA 5

The form most Virginia sellers reach for and almost none of them need. Directly under its own title, in bold, it prints the condition: do not use this form if a title exists for this vehicle. A Virginia certificate already carries the mileage disclosure inside Section A, so this stands in only where there is no certificate to write on - a vehicle DMV has never titled, or one being titled here for the first time on other proof of ownership.

Written against VSA 5 (07/01/2021), issued under Va. Code 46.2-629 and 49 U.S.C. 32701. DMV's own forms index describes this as a form for recording odometer readings on new vehicles or for a lessee reporting to a leasing company - a description that sounds like it might cover a private sale. The form itself is narrower than the index entry, and the sentence printed on the form wins: do not use this form if a title exists for this vehicle.

Two documents, and they are not the same thing. Take the blank VSA 5 from the dmv.virginia.gov copy so you get the revision that is current today.

Step 1 · the form itself Blank VSA 5 — Odometer Disclosure Statement PDF at dmv.virginia.gov · new tab

Filled in

What a completed one looks like

This is the actual VSA 5, rendered from the PDF the Virginia Department of Motor Vehicles 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 Virginia DMV VSA 5 filled in for a 1998 Chevrolet K1500 with no existing certificate: the vehicle identification number, an odometer reading of 184206, the actual mileage box ticked, seller Della M. Yancey of Chesapeake and buyer Aurelio J. Santos of Suffolk with their addresses and signatures. — Filled in for the only situation it covers - a vehicle with no title to write the disclosure on. The seller here is applying for a Virginia certificate on an affidavit; the mileage has to be disclosed somewhere, and this is it.

Field by field

Every line, in the order you meet it

1
You fill this in
Vehicle information
The full VIN, then make, body type, model and year.
Watch out: With no certificate to copy from, this comes off the vehicle itself. Photograph the VIN plate before you write it down.
2
You fill this in
The odometer reading
Whole miles into the box at the top right of the seller's block.
Watch out: No tenths. Round nothing - write what the instrument shows, with the decimal digit left off.
3
You fill this in
One tick of four
Actual mileage, in excess of mechanical limits, not the actual mileage, or exempt in a prior state of title.
Watch out: Actual mileage is a positive claim, not a default. If the instrument is broken, the third box is the honest answer and it is better made now than argued about later.
4
You fill this in
Seller certification
Printed name, signature, date, then street address, city, state and ZIP.
Watch out: The address is asked for because this form may be the only record of who made the disclosure. A car with no title has no other paper trail.
5
The buyer fills this in
Buyer certification
The buyer prints, signs, dates and gives their own address, acknowledging that they received a copy.
Watch out: Give them the copy at the same time. The certification is about receipt, and signing for something you were not handed is how disputes start.

At a glance

What goes where

On the form	What to put in it
Vehicle information	Vehicle identification number across most of the row, then make, body type, model and year in four narrow boxes to the right.
Odometer reading	One box, top right of the seller's block, labelled no tenths.
Check one box only	Four ticks and the instruction is explicit that only one is used: the reading is the actual mileage of the vehicle; it is in excess of the odometer's mechanical limits; it is not the actual mileage, with a bracketed warning of odometer discrepancy; or the vehicle was exempt from disclosure in prior state of title, which requires the out-of-state title showing the exemption.
Seller certification	Printed name, signature and date, then a second row for the seller's street address, city, state and ZIP code.
Buyer certification	A single printed sentence - by signing below I acknowledge and certify that I have received a copy of this completed form - then the buyer's printed name, signature, date and address.
The statutory footnote	The instruction line cites Sections 409, 412 and 413 of the Motor Vehicle Information and Cost Savings Act of 1972 and Section 46.2-629 of the Code of Virginia, and warns that failure to complete it or providing false information may result in fines and/or imprisonment.

What gets this one rejected

•Using it alongside a Virginia certificate. The bold line under the title rules it out, and a disclosure in two places invites the two to disagree.
•Ticking more than one of the four statements. The heading is check one box only.
•Recording tenths of a mile. The odometer box says no tenths and a decimal in it is a reading DMV cannot record.
•Leaving the buyer's block empty. The buyer is certifying that they received a copy, and without that signature the form has only done half its job.
•Reaching for the exempt-in-prior-state tick without the out-of-state title. The line itself requires the applicant to present it.

Rules that decide whether it is accepted

•Where it genuinely belongs. A vehicle with no Virginia title record - one coming in on an affidavit in lieu of title, or first titled here on a manufacturer's certificate of origin. The disclosure has to exist somewhere, and with no certificate this is the somewhere.
•Both parties keep a copy. The buyer's certification is about receipt, not about agreement, and the federal rule behind it exists so that a mileage claim can be traced back years later.
•It carries no vehicle history. There is no title number and no owner history on this form. It is a snapshot of one reading at one transfer, which is why it never replaces a certificate.

Every line here was read off VSA 5 (07/01/2021) itself — the PDF is here — and off the Virginia Department of Motor Vehicles pages. This is plain-language help with a form, not legal advice, and where our wording and the agency's differ, theirs governs.

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

How to fill out Virginia VSA 5

What a completed one looks like

Every line, in the order you meet it

Vehicle information

The odometer reading

One tick of four

Seller certification

Buyer certification

What goes where

What gets this one rejected

Rules that decide whether it is accepted

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