Name:

Address: _____________________________________________________________________

_____________________________________________________________________

City: ______________________    State / Province: ___________    Zip Code: ___________

Phone: ___________________________________ Email:

Lost / Damage / Incomplete: ______________________________________________________

If item is damaged, please describe and attach picture of damage: ______________________

_______________________________________________________________________________

_______________________________________________________________________________

Describe condition of package: ____________________________________________________

I hereby certify that all information on this form is accurate and truthful. The submission of a false, fictitious or fraudulent statement may result in imprisonment of up to 5 years and a fine of up to $10,000.00 (18 USC 1001). In addition, a civil penalty of up to $5,000.00, and an assessment of twice the amount falsely claimed may be imposed (31 USC 3802).


Signature: ________________________________________    Today's Date:  

Those customers filing more than one claim may experience a delay in payment due to an increase in investigative time.


WARNING: Any fraudelent claims will make the shipper and/or consignee liable for prosecution for mail fraud under Federal Criminal Code.