D. Assigned Code(s) of Selected Letter(s)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
E. Postal Service Use Only
Total number of letters selected. (Not to exceed 10)
Employee’s Initials
Date (MM/DD/YYYY)
Customer ID# (if applicable)
6012-I
PS Form
, December 2017 (Page 2 of 2) PSN 7530-09-000-9209