Form I-312A Revocation of Designation of Attorney In Fact

OMB No. 1653-0041
Exp. XX/XX/20XX

DEPARTMENT OF HOMELAND SECURITY

U.S. Immigration and Customs Enforcement
REVOCATION OF DESIGNATION OF ATTORNEY IN FACT

(For an Obligor to Revoke a Previous Appointment of an Attorney in Fact made using ICE Form I-312)
I,

, of

as principal

(Obligor)

(Address)

and obligor on Cash Bond No.

, in the amount of $
, A No.

(Alien's Name)

, executed in favor of

, appointed

,

(A Number)

(Attorney in Fact's Name)

of

, to be my attorney in fact and to receive the
(Attorney in Fact's Address)

proceeds of this bond once it was breached or canceled. I appointed this individual on

.
(Date)

Today, on this date,

, I hereby revoke and terminate this appointment. This revocation will not be effective unless

it is properly notarized, and until the original form is received by the Bonds Unit, Financial Operations – Burlington, U.S. Immigration
and Customs Enforcement, P.O. Box 5000, Williston, VT 05495, its validity confirmed, and it is entered into an ICE database. If this
revocation is invalid, the Bonds Unit will return it with a brief explanation of why it is not acceptable.
IN WITNESS WHEREOF, I have set my hand and seal on the

day of

in the year

.

Signature of Obligor (Principal)
Obligor Information (Please Print)
Name:
Address:

TIN or SSN
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.

Notary Public, State of:
My commission expires:

Date:

Notary Seal

REVIEWED AND ENTERED INTO ICE DATABASE
ICE Form I-312A (5/14)

Page 1 of 2

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.
Department of Treasury 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.
Department of Treasury 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. Department of Justice or 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 (0.5 hour) 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. Immigrations and Customs
Enforcement, 801 I Street, NW, Washington, D.C. 20536-5800 (Do not mail your completed revocation of attorney in fact to this
address).

ICE Form I-312A (5/14)

Page 2 of 2