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. Total Charges to be Added to Selling Price .................................... $
D. 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. Total Deductions ............................................................................................................................... $
F. 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: Title:

Signature: Date:

CBP Form 4632 (07/07)