PC Postage® Products Refund Request for Unused Postage

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Print this page Claim #: 18141

Customer: sign, and mail all pages of this completed form, along with mailpieces displaying valid indicia, within 30 days of the indicium date to your PC Postage provider. Labels with valid indicia should be unmailed and include both the address label and indicium label. The mailing address can be found in Part 3 below. Please note unsigned forms will not be processed.
Privacy Act Statement: The collection of this information is authorized by 39 USC 401, 404, and 1206; Pub. L. 104-134. This information will be used to reimburse you when no service is rendered. As a routine use, the information may be disclosed to an appropriate government agency, domestic or foreign, for law enforcement purposes; where pertinent, in a legal proceeding to which the USPS is a party or has an interest; to a government agency in order to obtain information relevant to a USPS decision concerning employment, security clearances, contracts, licenses, grants, permits, or other benefits; to a congressional office at your request; to an expert consultant, or other person under contract with the USPS to fulfill an agency function; to a Federal Records Center for storage; to the Office of Management and Budget for review of private relief legislation; to an independent certified accountant during an official audit of the USPS finances; to an investigator, administrative judge or complaints examiner appointed by the Equal Employment Opportunity Commission for investigation of a formal EEO complaint under 29 CFR 1614; to the Merit Systems Protection Board or Office of Special Counsel for proceedings or investigations involving personnel practices and other matters within their jurisdiction; to a labor organization as required by the National Labor Relations Act; to the Department of the Treasury for cross-matching under the Treasury Offset Program; and to a requestor, the name and address of the owner of leased property, or of the payee when different from the owner. Completion of this form is voluntary; however, if this information is not provided, a refund will not be considered.

Part 1 - Application Information (To be completed by customer)
Customer/Company Name
Elizabeth Hook / Elizabeth Hook
Mailing Address
41 Old Trail Rd
Liverpool, PA 17045
PC Postage Device ID
Email Address
Contact Phone
Certification Statement: I certify that I have not used the postage I am submitting for a misprint refund and that the United States Postal Service has not performed any service related to this postage. I understand that this claim will be verified by the United States Postal Service and/or its authorized representative. I also understand that filing false, fictitious or fraudulent refund requests for the return of U.S. postage is punishable under criminal laws of the United States, including 18 U.S.C. 1001.
Date Of Request

Official Use Only
Part 2a - Unused PC Postage Indicia Submitted
Part 2b - Verification of Indicia
Date in Indicia # of Pieces Face Value
Each Piece
Total Face Value Verified Amount
(if different then Total Face Value)
09/19/2006 1 $6.15 $6.15
Total Postage Face Value $6.15
Part 3 - Calculation and Verification Of Refund
Total Verified Amount
Reimbursement to be Reported to USPS
Less Processing Fee N/A Number Of Indicia
Total Refund Claimant is Entitled
Reimbursable Amount
PC Postage Provider

PO BOX 6026
INGLEWOOD CA 90312-6026
Certifying Employee Signature
Date Refund Issued

Part 4 - Certification of Destruction of PC Postage Indicia - (USPS use only)
Indicia must be destroyed to prevent reuse. Signature below certifies that indicia listed above were destroyed.
Destroyed By Name

Date Destroyed (mm/dd/yyyy)