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December 21, 2017 <br /> Shipper 071Y42 <br /> ' Page 3 of 3 <br /> iY <br /> REQUEST FOR CLAIM PAYMENT <br /> If you are filing your claim electronically, please complete this form online. To fax or mail your claim, <br /> please complete this form, using black ink only. Include the lesser of your actual cost of the <br /> merchandise, replacement cost or repair cost if repairable. Specify which cost you are including. <br /> Include your transportation charges. The preceding letter includes instructions on filing a claim and a <br /> toll free fax number for your convenience 24 hours a day. For future reference, this claim is identified <br /> by Claim Number 5867987701A, and Shipper Number 071Y42. <br /> Declaration:By my signature below, 1 certify that the information provided in this Request for Claim Payment and all <br /> communications related to this Request, including but not limited to statements as to the actual content and value of <br /> items that have been lost or damaged, are true and accurate to the best of my knowledge, and that this Request has <br /> been submitted in good faith. <br /> Signature of Claimant: /Y("k 8. ,Jo-y`te-r Name: Mark B. Joyner Date: 12/21/2017 <br /> (print) (mm/dd/yyy) <br /> SHIPMENT TO: DEPARTMENT OF NATURAL RESOUR <br /> COLORADO DIVISION OF RECLAMA <br /> 1313 SHERMAN ST STE ROOM 215 <br /> DENVER CO 802032243 <br /> Shipper Number .. .. ......... ..071Y42 Pickup Date....... .........................11/07/17 <br /> Number of Parcels........................1 Weight.. .. ............................... ...1 LBS <br /> Tracking Identification Number..1Z071Y420190149524 <br /> Merchandise.................................BUSS LETTER FROM EXXON MOBILE <br /> Could this merchandise be replaced for your customer? Yes_ No x <br /> If damaged,is the merchandise repairable? Yes_ No .X <br /> If damaged, UPS may issue a Recovery Call Tag to take possession of the merchandise. <br /> Quantity Merchandise Description Specify Dollar Amount and Indicate Whether <br /> Actual, Replacement or Repair Cost <br /> 1 Business Letter n/a <br /> 1 Check-Bank Of America to SHIPPER#1258408760 $633 00 <br /> Transportation Charges: $12.83 <br /> Total Amount Requested: $645 83 <br /> Please provide a contact name and telephone number in the event further communication is necessary. <br /> CONTACT NAME: Mark Joyner PHONE: 832-624-9123 <br /> Please provide any additional Tracking Number(s)for the above shipment: <br /> Tracking <br /> Numb r <br /> To File a claim by Fax: <br /> Fax this completed Request for Claim Payment form and your other documents to: 1-888-458-7703 <br /> To File a claim by Mail: <br /> Mail this completed Request for Claim Payment form and your other documents to: <br /> Claims Processing Center <br /> P.O. BOX 1265 <br /> Newport News VA 23601-1265 <br /> T890NTFM:000A0000 LDI 20 <br /> **AAWVREH603** <br />