Small Parcel/Cargo Loss Reimbursement
Buyer/Recipient Affidavit
Reference Number: __________________ Claim Number:______________
(For Internal Use Only) (For Internal Use Only)
Buyers / Recipients Information
Name:_______________________________________________________________
Street Address / PO Box ______________________________________City________________________
State/Province_____________________Postal/Zip Code___________Country_____________________
Phone:______________________________Email_____________________________________________
Claim Details
Tracking Number: ______________________________________________________________
Claim Amount: _________________________________________________________________
Claim Type: Lost Damage Incomplete
If Item is damaged, please describe and attach picture of damage:_______________________________
_____________________________________________________________________________________
Describe condition of package:____________________________________________________________
_____________________________________________________________________________________
Seller /Shipper Information
Name:________________________________________________________________________________
Phone:__________________________________Email_________________________________________
I hereby certify that all information on this form is accurate and truthful under Federal Law and under penalty of
perjury, under the laws of the state of California. The submission of a false, fictitious or fraudulent statement may
result in imprisonment of up to 5 years and a fine of up to $10,000 ( 18 USC 1001 ). In addition, a civil penalty of up
to $5,000, and an assessment of twice the amount falsely claimed may be imposed ( 31 USC 3802 ).
Buyer/Recipient Signature:_______________________________________Date:___________________
Warning: Any fraudulent claims will make the shipper and/or consignee liable for any prosecution for mail fraud
under the federal crime code.
Should the insured and/or shipper submit a false, fictitious or fraudulent statement,
it will result in the claims being denied.
Questions? Contact GlobalPost at 888-899-1255. M-F, 6 AM – 6 PM PT
For Lost or Damaged Parcels shipped by GlobalPost or Global Advantage Program
v.19.01.15
