Ps Form 6510 - Death Gratuity Payment Authorization - United States Postal Service (Page 2 of 2) in pdf

Ps Form 6510 - Death Gratuity Payment Authorization - United States Postal Service Page 2

YOUR SIGNATURE MUST BE NOTARIZED

Signature: _____________________________________________ Date: ______/______/_______

STATE OF _____________________________________________

COUNTY OF ___________________________________________

SWORN TO AND SUBSCRIBED before me, a NOTARY PUBLIC for the State and County aforesaid, this ______ day of

_____________________, ______________.

__________________________________________________________

Notary Public

SEAL

My Commission Expires: ______________________________

Part D: Authorization for Payment by AVP or HQ Vice President

Instructions: This section is to be completed by the AVP or the appropriate HQ vice president. It must then be sent to the

address provided below.

Name: ________________________________________________ Title: __________________________________________________

Signature: _____________________________________________ Date: ______/______/_______

Amount of Gratuity Payment: $10,000.00

Date Sent to San Mateo Accounting Service Center: ________/_______/_________

Sent by: _________________________________________________________________

Charge to: GLA # 51273.000

Finance # _______________________

MAIL COMPLETED FORM TO

San Mateo ASC Manager Field Payables, 2700 Campus Drive, San Mateo CA 94497-9400

6510,

PS Form

January 2015

Ps Form 6510 - Death Gratuity Payment Authorization - United States Postal Service Page 2