DEPARTMENT OF HOMELAND SECURITY
U.S. Customs and Border Protection LIEN HOLDER FINANCIAL STATEMENT
INSTRUCTIONS TO LIEN HOLDER: Complete and sign this form. Return it along with a certified copy of the purchase agreement/sale contract, and your notarized petition for remission/mitigation.
Seizure No.
Cash Selling Price ......................................................................................................................... Added Miscellaneous Charges (Tax, Transfer Fees, etc.) ...............................................................................
$ $ $
A.
Total Selling Price ............................................................................................................................. Less Trade-In ................................................................... Less Cash Down Payment ...............................................
$ $ $ $
Total Deductions ...............................................................................................................................
B.
Unpaid Balance of Selling Price ........................................................................................................ Plus Finance Charges ...................................................... Plus Contract Insurance Premium .................................... Plus Other Contract Charges ...........................................
$ $ $ $ $
C. D.
Total Charges to be Added to Selling Price ....................................
Total (B + C) ...................................................................................................................................... Less Total Payments ...................................................................... Less Unearned Finance Charges ................................................... (Add 30 days computed interest as of the date of seizure) Less Unearned Service Contract .................................................... (See 8 CFR 274.1(J) or Other Extended Warranty) Less Unearned Insurance ...............................................................
$ $ $ $ $ $
E. F.
Total Deductions ............................................................................................................................... Petitioner's Recognized Equity (D - E) ..............................................................................................
I certify that the information above is true and correct and that the payments and/or credits are correct as shown. I understand and acknowledge that falsification of any information on this form may result in a fine up to $10,000 and/or imprisonment for not more than 5 years (18 USC 1001). Printed Name: Signature: Title: Date:
CBP Form 4632 (07/07)