First Name

Last Name

Affiliated with a private corporation or law firm and am seeking this information for use in the company’s business. (Please check if you are)

Yes

Company/Firm Name

Please provide this additional information.

On Behalf Of (if applicable)

If you are submitting this on someone else's behalf.

Street Address

We need to have an address on file

Address (continued)

If you need more room

City

State

Abbreviation is fine

Zip Code

Daytime Phone Number

A phone number is required in case we cannot reach you by e-mail.

Alternate Phone Number

An alternate phone number is requested but not required.

Fax Number

If you would like to receive anything via Fax.

E-Mail Address

We need your e-mail address in case we need to contact you.

Report Name or Number (if known)

Please include name(s), date(s), and location(s) if applicable

Enter Text Below:

Privacy Act Statement: The collection of this information, which will be used principally for investigations or audits into fraud, waste, and abuse in connection with the programs and operations of the U.S. Postal Service (USPS), is authorized by 39 USC 404, 18 USC 3061, and 5 USC, App. 3. It may be disclosed to an appropriate government agency, domestic or foreign, for law enforcement purposes; if pertinent, in a legal proceeding to which the USPS is a party or has an interest; to a government agency in order to obtain information relevant to a USPS decision concerning employment, security clearances, contracts, licenses, grants, permits or other benefits; to a government agency upon its request when relevant to its decision concerning employment, security clearances, security or suitability investigations, contracts, licenses, grants or other benefits; to a congressional office at your request; to an expert, consultant, or other person under contract with the USPS to fulfill an agency function; to the Federal Records Center for storage; to the Office of Management and Budget for review of private relief legislation; to an independent certified public accountant during an official audit of USPS finances; to an investigator, administrative judge or complaints examiner appointed by the Equal Employment Opportunity Commission for investigation of a formal EEO complaint under 29 CFR 1614; to the Merit Systems Protection Board or Office of Special Counsel for proceedings or investigations involving personnel nvestigation, trial or hearing; to obtain the cooperation of a witness or informant, or to notify of the status of the case; to a party or their attorney to discuss settlement, plea bargaining or discovery proceedings; to an agency or individual concerned with maintenance, extradition or release of a person held in custody; to a foreign country pursuant to an international treaty, convention or executive agreement; to the public, news media, trade associations or organized groups, if it is of interest, on accomplishments of the Postal Service or its employees; to a foreign country when apprehending or returning a fugitive to a jurisdiction seeking return; to American Insurance Association Index System members if it relates to accidents or injuries. Completion of this form is voluntary; however, the Office of Inspector General may not be able to address your complaint if the information is not provided. The USPS customer privacy policy may be found at www.usps.com.