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_SETUP.1
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OC_CLM.BLD
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1997-07-22
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3KB
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134 lines
#100
@001 Enter the name of the CLAIMANT:
~Enter the name of the person requesting a refund of freight
~charges.
@002 Enter street address of the CLAIMANT:
~Enter the street address of the person requesting the refund.
@003 Enter city, state zip code of the CLAIMANT:
~Enter the city, state and zip code of the claimant.
@004 Enter the name of the CARRIER:
~Enter the name of the carrier to whom this claim is being made.
@005 Enter the street address of the CARRIER:
~Enter the street address where the carrier is located.
@006 Enter the city, state zip code of the CARRIER:
~Enter the city, state and zip code where the carrier is located.
!007 Enter the amount of overcharge in numerals:
~Enter, in dollar format, the amount of the claimed overcharge.
#end control section
#100
CLAIM FOR OVERCHARGE
Date:____________________________________
Claimant's Name: @001
Address of Claimant: @002
@003
Name of Carrier: @004
Address of Carrier: @005
@006
This claim for $ @007 (!007 dollars) is made against the carrier
named above by @001, 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