Date:____________________________________ 

Claimant's Name: _____________________________

Address of Claimant:__________________________
___________________________ 

Name of Carrier: _____________________________
Address of Carrier: __________________________ 
__________________________ 

This claim for $ ___________________ (__________________________
_____________ & ____/100 dollars) is made against the carrier
named above by _________________________, Claimant, for overcharge
in connection with  the following shipment(s): 


Description of Shipment:____________________________ 


Name and address of Shipper:_________________________ 


Shipped from ____________________________ to ____________________ 


Final Destination: ______________________ Routed Via ____________ 


Bill of lading issued by ___________________________ (Company) on 

the __________________ day of _________________, 19___, 


Paid freight bill No. _________________ Truck No. _____________  

and initials ___________________________, 
Name and Address of recipient __________________. 
Nature of Overcharge:__________________________ 


	DETAILED STATEMENT SHOWING HOW AMOUNT CLAIMED IS DETERMINED 


	Number of packages ___________________, articles  
_______________, weight ___________, rate ___________, charges  
______________, amount of overcharge ________________ Dollars. 


	Authority for rate or classification  
claimed:_____________________________________________________ 


	In addition to the information given above, the following 
documents are submitted in support of this claim: 

(___________) 1. Original Bill of lading, if not previously 
surrendered by carrier. 

(___________) 2. Original Paid freight ("expense") bill. 

(___________) 3. Original Invoice or Certified Copy 

(___________) 4. Weight Certificate or certified statement when 
claim is based on misrouting or valuation. 

(___________) 5. Other Particulars obtainable in proof of loss or 
damage claimed: ____________________________________________. 

Remarks:________________________________________________________ 
________________________________________________________________ 
________________________________________________________________. 

The above statement of facts is hereby certified as correct. 

Dated:________________________________. 



______________________________________ 
CLAIMANT