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

OMB No. 1653-0045
Expiration 3/31/2016

State of

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)

(Zip Code)

That I am the surety on an immigration bond executed in behalf of
(Alien's Name)

at

on
(Office where bond was posted)

(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 (3/16)

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Privacy Statement
Authority and Purpose: The Immigration and Nationality Act, as amended, (8 U.S.C. 1103, 1183, 1226, 1229c, and
1363) and Executive Order 9395 authorize the collection of this information, including your Social Security number (SSN),
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, including your SSN, 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, PRA Officer, 801 I Street, N.W., Room 700,
Washington, DC 20536 (Do not mail your completed application to this address.)

ICE Form I-395 (3/16)

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