Usps - Application For Refund Of Fees, Products And Withdrawal Of Customer Accounts

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Application for Refund of Fees, Products
and Withdrawal of Customer Accounts
(Use blue or black ink and print within the boxes.)
Part 1 - Application (Customer complete and submit to local Post Office
for processing)
Customer/Company Name
Attention
Mailing Address (Address to which the funds will be mailed)
Apt. or Suite No.
City
State
Telephone No. (Include area code)
ZIP + 4®
Amount of Refund Request
Customer Account No. or Postage Meter No.
$
,
,
.
X
Signature of Customer
Date of Request (MM/DD/YYYY)
Privacy Act Statement
Your information will be used to process and respond to your transaction. Collection is authorized by 39 USC 401, 403, 404, 410, 2008 & 31 USC 7701.
Providing the information is voluntary, but if not provided, we may not process your refund request. We do not disclose your information to third parties without
your consent, except to facilitate the transactions, to act on your behalf or request. We may only disclose your information as follows: in relevant legal pro-
ceedings; to law enforcement when the USPS ® or requesting agency becomes aware of a violation of law; to a congressional office on your behalf; to con-
tractors and other entities aiding us to fulfill the service (service providers); to entities authorized to perform audits; to labor organizations as required by law;
to federal, state, local or foreign government agencies regarding personnel matters; to the Equal Employment Opportunity Commission; and to the Merit
Systems Protection Board or Office of Special Counsel. For information regarding our Privacy Policy visit
Request Disbursement For: (Select the appropriate box)
Refund Postage and Fees (AIC 553)
Refund for Postal Service™ Related Products (AIC 608)
(e.g., merchandise)
Post Office PVI Error - Issued Locally
(Attach spoiled/misprint label to this form)
Refund Miscellaneous Non-Postal Service Revenue - (AIC 624)
(Previously recorded into AIC 126)
Refund of Special Service Fees - Service not rendered
(Certified Mail,™ Registered Mail,™ Delivery Confirmation™, etc.)
Express Mail® Refunds (AIC 676)
(Postage and fees for service failure or not rendered)
Spoiled/Unused Printed Customer Meter Postage (AIC 526)
(Legible postage meter stamps must be submitted to USPS.)
Sure Money® Refund (AIC 645/646) - Issued Locally
Refund of Permit Postage and Fees (AIC 528)
Withdrawal from Advance Deposit Account (AIC 470/453)
(Damaged printed mailing, refund of annual fee)
Close Account
Partial Refund
Refund of Fees and Retail Services (AIC 535)
Other Refunds (AIC ________________)
(PO Box keys and service fees)
Explanation:_______________________________________________
Value Added Services (AIC 541) - Refunds to mailing agents that perform value added service and submit mail at discounted rates. This refund
will require the Customer Tax Identification Number (TIN).
Customer TIN#
Part 2 - Verification of Disbursements (This area is for Official use only)
Approved Amount of Disbursement
Post Office
$
,
,
.
Post Office ZIP + 4
Finance Number and Unit ID
Telephone No. (Include area code)
Print Contact Name
Certifying Employee Signature
Date
Witness Signature
Date
3533,
PS Form
November 2006 (Page 1 of 2) PSN 7530-01-000-9932

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