Mail delivery by the current/proposed method imposes an extreme physical hardship on the customer named below,
(Domestic Mail Manual 508 2.1.2).
A. CUSTOMER INFORMATION
Name of Customer
Delivery Address
City State ZIP Code™
Telephone Email
Customer Signature (required) Date
B. CURRENT TYPE OF DELIVERY (Check one)
Curbline/Rural Box, Apartment Box Neighborhood Delivery (Cluster Box)
Other (please describe)
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C. TYPE OF DELIVERY REQUESTED
Type of Delivery Requested
Physical Reason for Hardship Request (attach additional pages if needed)
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D. REQUESTS FOR EXCEPTION
Requests for exception to current delivery mode to extreme physical hardship must be accompanied by evidence of the
existence of the source of said hardship for example, enclosures, attachments, photographs, physician’s statement or other
suitable documentation. Advanced age, although a consideration, is not within itself a qualifying factor for a hardship exception.
Provide any information which would apply to your request.
NOTE: Approval of exception to current method of delivery due to hardship is temporary and will be void when the hardship
ceases to exist. The prevailing mode of delivery will then be reinstated. This request must be renewed annually (Postal Operations
Manual 631.52e).
POSTAL SERVICE USE ONLY
The above request for a hardship delivery exception is:
Granted Effective Date
Denied, reason (use back if needed)
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Postmaster/Manager Signature Date
District Manager Signature (Signature required only for denied requests.) Date
Request For Exception To Current/Proposed
Delivery Mode Due To Physical Hardship
PS Form 1528, August 2019
