Ps Form 3541-1 - Postage Statement - Periodicals printable pdf download

United States Postal Service

Post Office: Note Mail Arrival

Date & Time (Do Not Round-Stamp)

Postage Statement—Periodicals

One Issue or One Edition Unless Used as a Consolidated Statement

Publication Title and

Mailing Agent

Entry Post Office

(Printer or Consolidator)

Owner or News Agent Name

Name, Address, Telephone, Email

Name, State, and ZIP+4

CAPS Cust. Ref. No.

Printer/Consolidator Imprint Permit No.

CRID

Publication No.

Edition/Code

Mailer’s Mailing Date

Statement Seq. No.

For Automation Pieces,

No. and type

Enter Date of Address

of Containers

Matching and Coding

(Enter total number

of containers.)

Issue Date

Issue Frequency

Price Category

Processing Category

Trays

Regular

Letters

For Carrier Route Pieces,

Enter Date of Address

Nonprofit

Flats

Sacks

Matching and Coding

Classroom

Parcels

Pallets

Science-of-Agriculture

For Carrier Route Pieces,

Enter Date of Carrier

Weight per Copy for Issue

Weight of a Single

Number of Addressed Pieces

Number of Addressed

Ride-Along Piece

Excluding Addressed

Supplements

Route Sequencing

(Round off to 4 decimal places

Supplements

if necessary)

In-County

pounds

Consolidated

For Pieces Bearing a

Outside-

Postage Statement

Simplified Address Enter

Advertising Percentage

Statement for

Combined Mailing

County

Date of Delivery Statistics

Yes

in This Issue

bundles/containers

Mixed Class

File or Alternative Method

only (if applicable)

Single Class

Applicable Parts Completed (Select all that apply):

B–E

Total Part A

(page 2)

Part A—In-County Prices

(Postmaster: Report total Part A postage in AIC 224)

Part B—Outside-County Pound Prices

Total Part B

(page 3)

Part C—Outside-County Piece Prices

Total Part C

(page 4)

Part D—Outside-County Bundle Prices

Total Part D

(page 5)

Part E—Outside-County Sack/Tray/Pallet Prices Total Part E

(pages 6 & 7)

Outside-County Postage

Subtotal Parts B, C, D & E

Preferred Price Discount

Nonprofit, Classroom, Limited Circulation, Limited Circulation Science of Agriculture

(Add line B17, and parts C, D, and E Totals)

X .05 (all others enter zero)

Subtract the Preferred Price Discount from the Outside-County Postage

Part F—Outside-County Ride-Along

(page 8)

Total Outside-County Postage

(Postmaster: Report total Outside-County postage in AIC 135)

Total Postage

Add Total In-County Postage and Total Outside-County Postage

(AIC 224 + AIC 135)

The signature of the owner of the publication certifies acceptance of liability for and agreement to pay any revenue deficiencies assessed on this mailing, subject to appeal.

If an agent signs this form, the agent certifies that he or she is authorized to sign on behalf of the owner of the publication and that the owner of the publication is bound by

the certification and agrees to pay any deficiencies. In addition, agents may be liable for any deficiencies resulting from matters within their responsibility, knowledge, or control.

The owner of the publication hereby certifies that all information furnished on this form is accurate, truthful, and complete; that the mail and the supporting documentation

comply with all postal standards and that the mailing qualifies for the prices and fees claimed; and that the mailing does not contain any matter prohibited by law or postal

regulation. I understand that anyone who furnishes false or misleading information on this form or who omits information requested on this form, may be subject to criminal

and/or civil penalties, including fines and imprisonment. Privacy Notice: For information regarding our Privacy Policy visit

Signature of Owner or Agent

Printed Name of Owner or Agent

Name and Telephone of Contact Person

in Publisher’s Office

Post Office Computed Weight per Copy

USPS Employee’s Signature

Round Stamp (Required)

(Round off to 4 decimal places if necessary)

Payment Date

Print USPS Employee’s Name

pounds