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2. First Name
3. Last Name
5. Address
7. Phone Number
9. Email Address
11. Date of Damage
12. Time of Damage
13. Estimated Cost at Purchase
15. Description of Damage
17. Box Size
    -- Select One --SmallMediumLarge
18. Box Condition Before Damage
    -- Select One --Like NewGood FairPoor
19. Post Condition Before Damage
    -- Select One --NewGood FairPoor
21. Check one

    1. I agree that the City of Huber Heights will install one equivalent size, standard mailbox on a 4" x 4" treated post to replace the damaged mailbox and post described above. DI agree to accept fifty dollars ($50.00) as full and complete compensation for the damage to the mailbox and post described above.
    2. I agree to accept fifty dollars ($50.00) as full and complete compensation for the damage to the mailbox and post described above. I agree that this amount is full compensation for my damage and agree to replace the damaged mailbox at my sole cost and expense in compliance with requirements of the USPS and the City of Huber Heights standards/requirements.
23. I also acknowledge

    A: The above amount will be paid in the normal payment cycle of the City of Huber Heights which may be (30) days from this date: and 

    B: If my mailbox is replaced with substandard materials, the city of Huber Heights may deny claims later for damage to the replacement box 

    
    

25. I hereby certify under the penalties of perjury the following:

    1. All the information contained on this form is true and correct.

    2. In the event it is determined that the facts contained herein are untrue, the City may, after investigation, forward this claim to the Montgomery County Prosecutor for prosecution

27. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
29. Electronic Signature
30. Date
    Date
32. For Office Use

    
    

    Driver:_______________Truck Number: _________________ 

    Claim Approved by: _________Date:___________________

    
    

34. Please read the following
    Mailbox Replacement Policy
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

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