Ps Form 3600-R1 - Postage Statement - First-Class Mail And Priority Mail

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Post Office: Note Mail Arrival Date & Time
United States Postal Service
Postage Statement — First-Class Mail
and Priority Mail
Use this form for either First-Class Mail or Priority Mail. They may not be combined.
Permit Holder's Name and Address and
Telephone
Name and Address of
Telephone
Name and Address of Individual or
Email Address, If Any
Mailing Agent (If other
Organization for Which Mailing Is Prepared
than permit holder)
(If other than permit holder)
CAPS Cust. Ref. No.
Dun & Bradstreet No.
Dun & Bradstreet No.
Dun & Bradstreet No.
Post Office of Mailing
Processing Category
Mailing Date
Federal Agency Cost Code
Statement Seq. No.
No. & type of Containers
Letters
Flats
Weight of a Single Piece
Total Pieces
Permit Imprint
Type of
Automation Flats (DMM 301.3)
Precanceled Stamps
Postage
____ ____ . ____ ____ ____ ____ pounds
Parcels
Metered
Permit #
Total Weight
For Mail Enclosed Within Another Class
Periodicals
Standard Mail
Bound Printed Matter
Library Mail
Media Mail
Parcel Post
For Automation Rate Pieces, Enter Date of Address
For Automation Carrier Route Rate Pieces, Enter Date of
Matching and Coding (DMM 708.3.3)
Address Matching and Coding (DMM 708.3.3)
____ ____ / ____ ____ / ____ ____ ____ ____
____ ____ / ____ ____ / ____ ____ ____ ____
B
C
D
E
F
S
Parts Completed (Select all that apply)
A
Total Postage
(Add parts totals)
Rate at Which Postage Affixed (Check one) (DMM 234.1.1)
Postage Affixed
_________ pcs. x $ _____ . ______ =
Correct
Lowest
Neither
Net Postage Due
(Subtract postage affixed from total postage)
For USPS Use Only: 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.
AIC 121
Permit Imprint Only - Check One
(First-Class Mail)
Total Adjusted Postage Permit Imprint
PM: Report Total Postage in AIC:
AIC 237
(Priority Mail)
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
the mailing qualifies for the rates 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
Are postage figures at left adjusted from
Yes
No
mailer's entries? If yes, reason:
____ . ____ ____ ____ ____ pound
Total Pieces
Total Weight
Total Postage
Round Stamp (Required)
Check One
Presort Verification
Presort Verification
Not Scheduled
Performed as Scheduled
I CERTIFY that this mailing has been inspected
concerning: (1) eligibility for postage rates claimed;
(2) proper preparation (and presort where required);
(3) proper completion of postage statement; and
Date Mailer Notified
By (Initials)
Contact
(4) payment of annual fee (if required).
Verifying Employee's Signature
Verifying Employee's Name
Time
AM
PM
3600-R1,
January 2006
(Page 1 of 3) PSN 7530-07-000-6217
This form and mailing standards available on Postal Explorer at .
PS Form

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