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.) ............................................................................... $
Total Selling Price ............................................................................................................................. $
Less Trade-In ................................................................... $
Less Cash Down Payment ............................................... $
A.
Total Deductions ............................................................................................................................... $
Unpaid Balance of Selling Price ........................................................................................................ $
Plus Finance Charges ...................................................... $
Plus Contract Insurance Premium .................................... $
B.
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 .............