DEPARTMENT OF HOMELAND SECURITY
U.S. Customs and Border Protection
OMB No. 1651-0100
Exp. 11/30/2011
CBP Form 4609 (06/09)
PETITION FOR REMISSION OR MITIGATION OF FORFEITURES AND PENALTIES INCURRED
Notice: Use this form if you want U.S. Customs and Border Protection to decide your request for the release of property and/or relief
from liability incurred of the following mitigating circumstances.
Instructions: This form (Parts I - III) must be completed in English and signed.
In accordance with Title 19 U.S.C. 1618; CFR 171.1. I request U.S. Customs and Border Protection consider my petition for remission
or mitigation from forfeiture administratively in order to obtain the release of my property.
PART I
Seizure or Penalty Number
Date of Seizure Place of Seizure
Telephone Number
Full Name (First, Middle, Last)
Address
PART II
Instructions: Provide certified copies (or originals) of all bills of sale, purchase contracts, receipts, or any other documentary evidence
to establish your interest in the seized property. Failure to do so may result in denial of your petition.
Note: Use separate piece of paper when necessary.
A. Describe the property that was seized (i.e., 1999 Ford Truck VIN # 123A456B789C0)
B. State your interest in the seized property listed above. Are you the owner, lien holder, or otherwise?
C. State the facts and circumstances relied upon to justify relief from forfeiture. If the property was in someone else's possession at
the time of seizure, please provide an explanation how it came into their possession.
PART III
A false statement contained in a petition may subject the petitioner to prosecution under the provision of 18 U.S.C. 1001.
Paperwork Reduction Act Statement: An agency may not conduct or sponsor an information collection and a person is not required to
respond to this information unless it displays a current valid OMB control number and an expiration date. The control number for this
collection is 1651-0100. The estimated average time to complete this application is 14 minutes. If you have any comments regarding the
burden estimate you can write to U.S. Customs and Border Protection, Office of Regulations and Rulings, 799 9th Street, NW.,
Washington DC 20229.
Signature Date
