Free DEPARTMENT OF HOMELAND SECURITY - Federal

DEPARTMENT OF HOMELAND SECURITY

OMB No. 1651-0100 Exp. 10-31-2011

U.S. Customs and Border Protection

PETITION FOR RELIEF FROM FORFEITURE
Notice : Use this form if you want U.S. Customs and Border Protection to decide your request for the release of property. Instructions : This form (Parts I - IV) must be completed in English, signed and notarized. In accordance with Title 8, Code of Federal Regulations, Part 274, I request U.S. Customs and Border Protection consider my petition for relief from forfeiture administratively in order to obtain the release of my property. Seizure Case Number: Date of Seizure: Full Name (First, Middle, Last) Date of Birth (mm/dd/yyyy): City, State, and County of Birth: PART I Place of Seizure:

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. A. Describe the property that was seized, to include the year, make, model, and serial number or Vehicle Identification Number. Use continuation sheets if more space is needed.

B. State your interest in the seized property listed above. Are you the owner, lien holder, or otherwise? Use continuation sheets if more space is needed.

C. State the facts and circumstances, with satisfactory proof thereof, 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. Use continuation sheets if more space is needed.

PART III
I swear under penalty of perjury that all of the information provided is true and correct to the best of my knowledge and belief. Signature STATE OF COUNTY OF SIGNED AND SWORN TO BEFORE ME ON THIS Date

PART IV (Notary Public)
DAY OF NOTARY PUBLIC COUNTY

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 13 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.

MY COMMISSION EXPIRES:

CBP Form 4630 (06/09)

CONTINUATION SHEET
Seizure Case Number: A. Full Name (First, Middle, Last)

B.

C.

CBP Form 4630 (06/09)