Form 4609 PETITION FOR REMISSION OR MITIGATION OF FORFEITURES AND

DEPARTMENT OF HOMELAND SECURITY

OMB No. 1651-0100
Exp. 02/28/2022

U.S. Customs and Border Protection

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

Full Name (First, Middle, Last)
Address

Telephone Number

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.
Signature

Date

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, 90 K Street, NE, Washington
DC 20229.
CBP Form 4609 (3/19)

U.S. Department of Homeland Security (DHS) Privacy Act Statement
OMB 1651-0100, CBP Form 4609 Petition for Remission or Mitigation of Forfeitures and Penalties Incurred

This Privacy Act Statement serves to inform you of why DHS is requesting the information on this form.
AUTHORITY:
U.S. Customs and Border Protection (CBP) is authorized to collect the information requested on this form pursuant to Title 19, United
States Code (U.S.C.), Section 1618 and Title 19, Code of Federal Regulations (C.F.R.), Section 171.1.
PURPOSE:
CBP uses the information provided on this form as a basis for granting relief from forfeiture of seized property or penalty for onsite
mitigation. The form must provide a description of the property involved (if a seizure); the date and place of the violation or seizure;
the facts and circumstance relied upon by the petitioner to justify remission or mitigation; and if a seizure case, proof of interest in
seized property.
ROUTINE USES:
Consistent with DHS's information-sharing mission, the information requested on this form may be shared with other DHS
Components to carry out national security, law enforcement, immigration, or other homeland security functions. Information may also
be shared with appropriate federal, state, local, tribal, territorial, foreign, or international government agencies. This sharing will assist
DHS in exercising enforcement of current and former violators and alleged or otherwise suspected violators of CBP, immigration,
agriculture or other laws and regulations administered or enforced by DHS/CBP, and related parties involved in, or affected by, an
inquiry concerning the violation of CBP, immigration, agriculture or other law enforced or administered by DHS/CBP. A complete list
of the routine uses can be found in the system of records notice associated with this form, “DHS/CBP-013 - Seized Assets and Case
Tracking System, December 19, 2008 73 FR 77764” The Department's full list of system of records notices can be found on the
Department's website at http://www.dhs.gov/system-records-notices-sorns.

CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION:
Providing the information on this form is voluntary. However, if not filled out onsite at the time of the violation, CBP has nothing to
base the remission/release from forfeiture of seized property or penalty and/or justify mitigation.