PS 5054

Bulk Proof of Delivery Application Payment Authorization (10/2010)

Download and Print the PS 5054

Request may not be processed if the form is incomplete or illegible.

A. General Information

The party that will be paying for the records must complete this payment authorization form. If a third-party designee will be paying for the records, then the third-party designee must complete this form.

This form is required only for customers choosing the Pay As Compiled method of receiving records. It is not required for customers using Express Mail® Manifesting or Signature Confirmation™ service.

Prior to submitting this form, all applicants must complete and submit PS Form 5053, Bulk Proof of Delivery Application.

B. Payer Information — (To be completed by either the mailer or the third party who is responsible for payment.)

1. Company Name

2. Mailer ID Number (If you are a third-party designee, please provide your
client's Mailer ID(s) below in Section D)

3. Street Address (Number, street, suite, apt., etc.)

4. City

5. State

6. ZIP+4®

11. Fax Number

And much more...