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 4/30/2019

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. This affidavit will not be effective unless it is properly notarized, and until the original form is received by
the Bonds Section at 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 affidavit is invalid, the Bonds
Section will return it with a brief explanation of why it is not acceptable.

Signature
Subscribed and sworn to before me
At:
(Location)

On:

Obligor Taxpayer Identification Number
(Social Security Number)

(Date)

NOTARY PUBLIC (Signature):

Notary Seal

MY COMMISSION EXPIRES ON:
ICE Form I-395 (9/16)

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Privacy Notice
Authority: 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).
Purpose: ICE collects 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. Your SSN will be
used for tax reporting. Your SSN will also be used to confirm your identity.
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: For United States Citizens, Lawful Permanent Residents, or individuals whose records are covered by the
Judicial Redress Act of 2015 (5 U.S.C. § 552a note), your information may be disclosed in accordance with the Privacy
Act of 1974, 5 U.S.C. § 552a(b), including pursuant to the routine uses published in the DHS/ICE-004 Bond Management
Information System of Records Notice (BMIS SORN), which can be viewed at www.dhs.gov/privacy.
For all others, as appropriate under United States law and U.S. Department of Homeland Security (DHS) policy, the
information you provide may be shared internally within DHS 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
other purposes.

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, P.O. Box 5000, Williston, VT 05495.

ICE Form I-395 (9/16)

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