Form I-312 Designation of Attorney In Fact

DEPARTMENT OF HOMELAND SECURITY

OMB No. 1653-0041
Exp. 04/30/2022

U.S. Immigration and Customs Enforcement
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,

(Obligor)

, of

, as principal have made, constituted,

(Address)

and appointed, and by these presents do make, constitute and appoint

(Attorney in Fact)

of

my true and lawful

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. This designation 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 designation is invalid, the Bonds Section will return it with a brief
explanation of why it is not acceptable.
IN WITNESS WHEREOF, I have hereto set my hand and seal on the

day of

in the year

.

Signature of Obligor (Principal) (Sign in ink)

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.

Do Not Write in this Space - Agency Only
DATE
EXAMINED AND APPROVED AS TO LEGAL FORM
AND EXECUTION AND ACCEPTED.
ICE Form I-312 (4/19)

Notary Public, State of
My commission expires:

Notary Seal

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Privacy Notice
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. Immigration and Customs Enforcement, P.O. Box 5000, Williston, VT 05495.

ICE Form I-312 (4/19)

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