Form I-312 Designation of Attorney In Fact

DEPARTMENT OF HOMELAND SECURITY
U.S. Immigration and Customs Enforcement

OMB No. 1653-0041
Exp. 12/31/2015

DESIGNATION OF ATTORNEY IN FACT
(To accept on Obligor's behalf the return of cash or United States bonds or notes deposited to secure an immigration bond
upon cancelation of the bond for performance by Obligor.)
Bonded Alien A-File No.
Receipt No. (From Form I-305)

I,

, of

, as principal have made, constituted,
(Address)

(Obligor)

and appointed, and by these presents do make, constitute and appoint
(Attorney in Fact)

my true and lawful

of

attorney for me and in my name, place and stead to receive a refund of the deposit of cash or government obligations
in the penal sum of $

made by me on

as security for an

immigration bond for the release of

giving and granting unto my said attorney

full power and authority to do and perform all and every act and thing whatsoever requisite and necessary to be done
in and about the premises, as fully to all intents and purposes, as I might or could do if personally present, hereby
ratifying and confirming all that my said attorney shall lawfully do or cause to be done by virtue hereof.
IN WITNESS WHEREOF, I have hereto set my hand and seal on the

day of

in the year

.

Signature of Obligor (Principal)

Name, Address, TIN or SSN for Attorney in Fact

STATE OF
COUNTY
On the

day of

in the year

before me personally came

(Obligor) to

me known and known to me to be the individual described in and who executed the foregoing instrument and acknowledged to me
that s/he executed the same for the use and purpose therein contained.

DATE
EXAMINED AND APPROVED AS TO LEGAL
FORM AND EXECUTION AND ACCEPTED.

Notary Public, State of
My commission expires:

Notary Seal

ICE Form I-312 (03/09)

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 provide for the posting, maintenance,
cancellation, and breach of an immigration surety bond, and for associated financial management
activities, including collection of unpaid monies, reimbursement of the bond principal, and the calculation,
payment, and reporting of interest. The Internal Revenue Code (26 U.S.C. 6109) authorizes the collection
of the Social Security number (SSN).
Disclosure: Furnishing this information is voluntary. For cash bonds, your SSN is necessary to pay
interest through the U.S.Treasury Department and to comply with Internal Revenue Service requirements to
report interest payments.
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. Treasury Department to report interest
paid to an obligor, and to facilitate payments to or collection of monies owed by an obligor. DHS may also
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 - 76. F. Reg. 8761-8764 (February 15, 2011) - Privacy Act of
1974: U.S. Immigration and Customs Enforcement, DHS/ICE-004 Bond Management Information System
(BMIS) system of Records.
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: Department of Homeland Security,U.S.
Immigration and Customs Enforcement, Forms Management Office, 801 I Street, NW, Washington, D.C.
20536-5800 (Do not mail your completed application to this address.)

ICE Form I-312 (03/09)