Fillable Printable I395
Fillable Printable I395
I395
State of
County of
If Known: Bonded Alien A Number
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.
Signature
Subscribed and sworn to before me
At:
On:
(Location)
(Date)
Obligor Taxpayer Identification Number
(Social Security Number)
NOTARY PUBLIC (Signature):
MY COMMISSION EXPIRES ON:
ICE Form I-395 (2/09)
Notary Seal
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
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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) authorizes the collection of 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.
Disclosure: Submission of this form and the information contained on this form 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.
ICE Form I-395 (2/09)
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, 500 12th Street, S.W., Room 3138, Washington, DC
20536 (Do not mail your completed application to this address.)
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