PS 8165

U.S. Postal Inspection Service Mail Fraud Report (10/2012)

Download and Print the PS 8165

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Company Name First Name Last Name
Address
City State Country
Cell Phone (Include Area Code) Work Phone (Include Area Code) Home Phone (Include Area Code) Email A ddress
Fax Phone (Include Area Code) Website Address
First Name Last Name Age Range:
Address
City State Country
Cell Phone (Include Area Code) Work Phone (Include Area Code) Home Phone (Include Area Code) Email A ddress
Check one of the following: PLEASE RETAIN ANY ORIGINAL DOCUMENTS. IF NEEDED, YOU WILL BE CONTACTED.
U.S. Mail
Telephone __________________ Internet ISP __________________ Website __________________ Email _____________________
Other ______________________________________________________
On what date were you contacted? If by mail, do you have the envelope it was mailed in? Does the envelope have a permit number?
Yes No Permit Number__________________________
Permit State ___________________________
Check one of the following:
U.S. Mail
Telephone __________________ Internet ISP __________________ Website __________________ Email _____________________
Other ______________________________________________________
To what name and address did you mail your response? _________________________________________________________________________
Do you have a mailing receipt (Certified, Insured, or Express Mail)? Yes Mail Receipt Number: ______________________________
What did you receive?
How did it differ from what you expected?
How much did the company ask you to pay? Do you have the item? How was it delivered? U.S. Mail Private Courier
Yes No Other _____________________________
How did you pay? (check one)
Cash Postal Money Order (Provide Postal Money Order Number) _____________________________________________
Money Transfer Service (Provide Transfer Service Name & Number) _____________________________________________ Transfer Number _______________________________
Pay Pal Debit Card/Credit Card Check Other Money Order
Other (explain) ___________________________________________________________________________________________________________
________________ Date of Last Payment
/ /
Have you contacted the company or person about the complaint? Yes No
If yes, date of last contact If no, why? Address Unavailable Addressee Not at Address
Disconnected Telephone Unlisted Telephone Unanswered Telephone
Legitimate businesses appreciate feedback. Check the offer for the delivery time frame, usually six to eight weeks, then contact the company. Please wait two weeks after
contacting them before sending us this form. When a delivery time is not specified, a Federal Trade Commission rule mandates fulfillment within 30 days, unless you applied
for first-time credit with the company.
/ /
U.S. Postal Inspection Service
Mail Fraud Report

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