Ps Form 3605-R1 - Postage Statement - Package Services

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United States Postal Service
Post Office: Note Mail Arrival
Date & Time (Do Not Round-Stamp)
Postage Statement—Package Services
(Bound Printed Matter, Library Mail, Media Mail) and Parcel Select
Use this form for all Package Services. Library Mail and Media Mail may be combined.
Permit Holder
Mailing Agent
Mail Owner
Name, Address, Email, Telephone
(If other than permit holder)
(If other than permit
Name, Address, Telephone
holder) Name, Address
CAPS Cust. Ref. No.
CRID
CRID
CRID
Post Office of Mailing
Mailer’s Mailing Date
Federal Agency Cost Code
Statement Seq. No.
Hold For Pickup
No. and type
(HFPU)
of Containers
# of pieces
Sacks
Type of Postage
Processing Category
Total # of Pieces
SSF Transaction#
in Mailing
Permit Imprint
Flats
Flat Trays
Metered
Irregular Parcels
Total Weight
Permit #
Parcels/Machinable Parcels
Pallets
Customer Generated
Electronic Labels
For Barcoded Pieces, Enter Date
Packaging Based on
Weight of a
.
Other
of Address Matching and Coding
Single Piece
pounds
DelCon
Piece Count
Weight
SigCon
Combined Mailing
/
/
Both
Mixed Class
Single Class
Parts Completed (Select all that apply):
A
B
C
D
E
S
1
Subtotal Postage (Add parts totals)
Price at Which Postage Affixed (Check one).
Correct
Lowest
Neither
2
Postage Affixed -
=
Complete if mailing includes pieces bearing metered/PC Postage.
pcs. x $
.
3
Incentive/Discount Flat Dollar Amount -
4
Fee Flat Dollar Amount +
Net Postage Due (Line 1 + / - Lines 2, 3, 4)
5 Permit #
Additional Postage Payment (State reason)
Add additional payment to net postage due for
Total Adjusted Postage Affixed
affixed or permit imprint—choose one only.
Postmaster: Report Total Postage in AIC 131
Total Adjusted BPM Postage Permit Imprint
(Permit Imprint Only)
Postmaster: Report Total Postage in AIC 124
Total Adjusted Media Mail/Library Mail Postage Permit Imprint
(Permit Imprint Only)
Postmaster: Report Total Postage in AIC 211
Total Adjusted Parcel Select Postage Permit Imprint
(Permit Imprint Only)
Incentive/Discount Claimed:
Type of Fee:
The mailer’s signature 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 mailer and that the mailer 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 mailer 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.
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Signature of Mailer or Agent
Printed Name of Mailer or Agent Signing Form
Telephone
Weight of a Single Piece
Total Weight
Are postage figures at left adjusted from mailer’s entries?
Round Stamp (Required)
Payment Date
.
Yes
No If yes, reason:
pounds
Total Pieces
Total Postage
Presort Verification Performed? (If required)
Yes
No
I CERTIFY that this mailing has been inspected for
Date Mailer Notified
Contact
each item below if required:
(1) eligibility for postage prices claimed;
(2) proper preparation (and presort where required);
(3) proper completion of postage statement;
By (Initials)
Time
AM
(4) payment of annual fee; and
PM
(5) sufficient funds on deposit (if required)
USPS Employee’s Signature
Print USPS Employee’s Name
PS Form 3605-R1, January 2018 (Page 1 of 9) PSN 7530-08-000-3305
This form and mailing standards are available on Postal Explorer at .

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