Affidavit in Lieu of Lost Receipt of United States ICE for Collateral Accepted as Security

• Legal Form Number: I-395
• Section: U.S. Immigration and Customs Enforcement
• Issuer: U.S. Immigration and Customs Enforcement

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. 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 (Sign in ink)

Subscribed and sworn to before me

At:

On:

(Location)

(Date)

Obligor Taxpayer Identification Number

(Social Security Number)

NOTARY PUBLIC (Signature) (Sign in ink):

MY COMMISSION EXPIRES ON:

ICE Form I-395 (9/19)

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 9/30/2022

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