Ps Form 3602-R - Postage Statement Standard Mail
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1
2
3
4United States Postal Service
Comments:
Post Office: Note Mail Arrival Date & Time
(Do Not Round-Stamp)
Postage Statement — Standard Mail
Permit Holder's Name and Address and
Telephone
Name and Address of
Telephone
Name and Address of Individual or
Email Address, If Any
(800)-622-8836
Mailing Agent (If other
(507)-642-3297
Organization for Which Mailing is Prepared
Extension
than permit holder)
Extension
(If other than permit holder)
FIVE STAR PUBLISHING
HOUSE OF PRINT
M
PO BOX 998
PO BOX 6
A
FT DODGE IA 50501
MADELIA MN 56062-0006
I
L
E
R
CAPS Cust. Ref. No.
14776
CRID ______________________
CRID _________________
CRID ______________________
Post Office of Mailing
Processing Category
Mailer's Mailing Date
Federal Agency Cost Code
Statement Seq. No.
No. of Containers
MADELIA MN 56062
[ ] Letters
[ ] Catalogs
5STAR
1' MM Trays
11/09/2012
[X] Flats
2' MM Trays
Type of
Weight of a Single Piece
Combined Mailing
Total # of Pieces in Mailing
[ ] Marketing Parcels
2' EMM Trays
[X] Permit Imprint
Postage
[ ] Mixed Class
19,367
[ ] Parcels - Machinable
Total Trays
M
[ ] Precanceled Stamps
[ ] Single Class
[ ] Parcels - Irregular
Flat Trays
A
[ ] Metered
0.2027 pounds
[ ] CMM
Sacks
14
I
Pallets
10
L
Permit #
For Mail Enclosed Within Another Class
Total Weight
Other
I
[ ] Periodicals
[ ] Bound Printed Matter
48
N
3,925.6909
[ ] Library Mail
[ ] Media Mail
[ ] Parcel Post
G
For Automation Price Pieces, Enter Date of
For Carrier Route Price Pieces, Enter Date
For Carrier Route Price Pieces, Enter Date
For pieces bearing a simplified address enter date
Address Matching and Coding
of Address Matching and Coding
of Carrier Route Sequencing
of delivery statistics file or alternative method
11/05/2012
11/05/2012
11/05/2012
Move Update method:
[ ] Ancillary Service Endorsement [ ] FASTforward
[ ] NCOALink
[ ] ACS [ ] Alternate Method [ ] Multiple
[ ] OneCode ACS
[ ] n/a Alt. Address Format
Parts Completed (Select all that apply)
[ ] A [ ] B [ ] C [X] D [X] E [X] F [ ] G [ ] H [ ] L [ ] M [ ] S [ ] NSA
[ ] Mailpiece is a product sample.
1
Subtotal Postage
(Add Parts Totals)
P
7,591.64
[ ] Letter-size or flat mailpiece contains DVD/CD or other disk.
O
Price at Which Postage Affixed (Check one) Complete if the mailing includes pieces bearing metered or precanceled stamps.
2
S
pcs. x $
=
Postage Affixed
[ ] Correct
[ ] Lowest
[ ] Neither
T
A
3
Incentive/Discount Flat Dollar Amount
G
4
Fee Flat Dollar Amount
E
5 Permit #
Net Postage Due
__________
(Line 1 +/- Lines 2, 3, 4)
7,591.64
Additional Postage Payment (State reason)
U
U
For postage affixed add additional payment to net postage due;
S
Total Adjusted Postage Affixed
S
for permit imprint add additional payment to total postage.
P
E
S
Postmaster: Report Total Postage in
AIC 130
Total Adjusted Postage Permit Imprint
(Permit Imprint Only)
C
Incentive/Discount Claimed:
_______________________________
Type of Fee: _______________________________
E
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
R
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
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agrees to pay any deficiencies. In addition, agents may be liable for any deficiencies resulting from matters within their responsibility, knowledge, or control.
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The mailer hereby certifies that all information furnished on this form is accurate, truthful, and complete; that the mail and the supporting documentation
F
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
I
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
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may be subject to criminal and/or civil penalties, including fines and imprisonment.
Privacy Notice: For information regarding our Privacy Policy visit
A
Signature of Mailer or Agent
Printed Name of Mailer or Agent Signing Form
Telephone
T
I
Extension
O
N
Weight of a Single Piece
Are postage figures at left adjusted from
[ ] Yes
[ ] No
mailer's entries? If yes, reason:
____ ____ . ____ ____ ____ ____ pound
N
N
T
T
O
Total Pieces
Total Weight
O
O
N
O
N
U
U
S
S
B
P
B
P
P
Total Postage
P
E
O
E
O
Round Stamp (Required)
S
S
S
S
C
T
Payment Date
C
T
O
A
O
A
U
U
Presort Verification Performed? (If required)
M
L
M
L
S
S
[ ] Yes
[ ] No
P
O
P
O
Date Mailer Notified
Contact
E
E
L
L
N
I CERTIFY that this mailing has been inspected for
N
E
E
E
E
each item below if required:
O
T
!
T
!
O
(1) eligibility for postage prices claimed;
E
E
N
N
(2) proper preparation (and presort where required);
By (Initials)
Time
AM
D
S
D
S
(3) proper completion of postage statement;
L
L
I
PM
I
(4) payment of annual fee; and
Y
Y
I
T
I
T
(5) sufficient funds on deposit (if required).
N
E
N
E
USPS Employee's Signature
Print USPS Employee's Name
S
S
PS Form 3602-R, June 2012
(Page 1 of 4)
Facsimile (BCC Mail Manager 3.02.N)
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