Form I-395 Affidavit in Lieu of Lost Receipt of United States ICE f

DEPARTMENT OF HOMELAND SECURITY
U.S. Immigration and Customs Enforcement
Affidavit in Lieu of Lost Receipt of United States
ICE for Collateral Accepted As Security
State of

OMB No. 1653-0045
Expiration 1/31/2013

If Known: Bonded Alien A Number

County of

Date and Place of Birth
Receipt Number

I,

hereby duly sworn, depose and say:
(Obligor's Name)

That I reside at:
(Number)

(Street)

(City)

(State)

That I am the surety on an immigration bond executed in behalf of
at

(Office where bond was posted)

on

(Zip Code)

(Alien's Name)
(Date bond was posted)

That as collateral security under such bond I deposited with the Immigration and Customs Enforcement certain
securities as follows: (Amount of Bond)

That the receipt which was issued to me on the same day by the Immigration and Customs Enforcement for
such collateral security has been lost under the following circumstances: (Reason for loss of original I-305)

That if the said receipt is located, I promise to see that it is surrendered to the Immigration and Customs
Enforcement;
That there are no other claimants to the said collateral security and I have not assigned the same or any part
thereof or any interest therein to any other party;
That I, on behalf of myself, my heirs, administrators, executors or assigns, will protect the government of the
United States and any of its agencies, officers and employees and save them harmless from any claim,
loss or liability whatsoever which may or might arise by reason of the surrender to me of the said collateral
security without my producing the receipt issued therefore.

Subscribed and sworn to before me
At:

(Location)

On:
(Date)

NOTARY PUBLIC (Signature):

Signature

Obligor Taxpayer Identification Number
(Social Security Number)

Notary Seal

MY COMMISSION EXPIRES ON:
ICE Form I-395 (02/09)

Privacy Statement
Authority and Purpose: The Immigration and Nationality Act, as amended, (8 U.S.C. 1103, 1183,
1226, 1229c, and 1363) authorizes the collection of this information to permit an individual or company
to sign a notarized affidavit when the original Receipt of Immigration Officer-United States Bonds,
Notes or Cash (ICE Form I-305) is lost or missing.
Disclosure: Submission of this form and the information contained on this form is voluntary; however,
the obligor will be unable to reclaim the principal amount of the immigration bond unless this form or
the original ICE Form I-305 is provided to ICE.
Routine Uses: This information will be used by and disclosed to DHS personnel and contractors or
other agents who need the information to support the enforcement of immigration laws and the
provision of immigration benefits. DHS may share this information with the U.S. Justice Department
and other Federal and State agencies for collection, enforcement, investigatory, or litigation purposes,
or as otherwise authorized pursuant to its published Privacy Act system of records notice.
Public Reporting Burden
U.S. Immigration and Customs Enforcement is collecting this information as a part of its agency
mission under the Department of Homeland Security. The estimated average time to review the
instructions, search existing data sources, gather and maintain the data needed and completing and
reviewing this collection of information is 30 minutes (.50 hours) per response. An agency may not
conduct or sponsor, and a person is not required to respond to, an information collection unless it
displays a currently valid OMB Control Number. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden to the
Department of Homeland Security, U.S. Immigration and Customs Enforcement, 500 12th Street, S.
W., Room 3138, Washington, D.C. 20536 (Do not mail your completed application to this
address.)

ICE Form I-395 (02/09)