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United States Postal Service

Post Office: Note Mail Arrival

Date & Time (Do Not Round-Stamp)

Postage Statement—Nonprofit USPS Marketing

Mail Easy—Nonautomation Letters or Flats

This form may be used only for a single nonautomation price mailing of identical-weight pieces. Use PS Form 3602-N

for all other regular Nonprofit USPS Marketing Mail mailings. Checklists and other tools for mailers are available

on the Postal Explorer website at .

Permit Holder

Federal Agency Cost Code

Statement Seq. No.

Weight of a Single Piece

Name, Address, Email, Telephone

Total Pieces

Processing Category

Letters

Flats

pounds

USPS Nonprofit Auth. No.

Total Weight

Permit #

Mailpiece is a

product sample

CRID

Post Office of Mailing

Mailer’s Mailing Date

No. & Type

Letter-size or flat mailpiece contains DVD/CD or other disk

of Containers

Sacks

Type of Postage

Move Update Method

This is a Political Campaign Mailing

Yes

Alternative Method

Trays

Permit Imprint

Ancillary Service

Multiple

Endorsement

Precanceled Stamps

Pallets

OneCode ACS

Link

NCOA

This is Official Election Mail

Yes

Metered

n/a Alternative

ACS

Address Format

Total Postage (Add parts totals)

Price at Which Postage Affixed (Check one).

Correct

Lowest

Neither

Postage Affixed

pcs. x $

Complete if mailing includes pieces bearing metered/PC Postage or precanceled stamps.

Permit #

Net Postage Due (Subtract postage affixed from total postage)

Additional Postage Payment (State reason)

For postage affixed, add additional payment to net postage due;

Total Adjusted Postage Affixed

for permit imprint, add additional payment to total postage.

Postmaster: Report Total Postage in AIC 125

Total Adjusted Postage Permit Imprint

(Permit Imprint Only)

The mailer’s signature certifies that: (1) the mailing complies with DMM 703; (2) the income derived from the sale of any products or services advertised in the mailing is not

subject to the Unrelated Business Income Tax (UBIT) and any products and services advertised are substantially related to the nonprofit organization’s authorized purpose

within the meaning of 39 U.S.C. 3626(j)(1)(d)(ii)(I) and 26 U.S.C. 513(A); (3) the mailing if made by a voting registration official is required or authorized under the National Voter

Registration Act of 1993; and (4) it will agree to pay, subject to appeal, any revenue deficiencies assessed on this mailing. 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 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: