Free CBP Form 4632 – Lien Holder Financial Statement - Federal

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)