Application for Delivery of Mail Through Agent

See Reverse for Instructions, Denitions, Agreement Terms, and the Privacy Act Statement.

1. Private Mailbox (PMB) Information 8. Photo ID Information for Applicant

1a. Date PMB Opened 1b. Date PMB Closed 8a. Applicant’s Name 8b. Applicant’s ID Number

2. Commercial Mail Receiving Agency (CMRA) Place of Business Information

8c. Issuing Entity 8d. Expiration Date on the ID

2a. Street Address to be Used for Delivery

2b. PMB #

2c. City 2d. State 2e. ZIP + 4

8e. Photo ID type (check one)

* U.S. State/Territory/Tribal Driver’s or Nondriver’s ID Card

* Uniformed Service ID * Passport * Certicate of Naturalization

3. Type of Service Requested

* U.S. Access Card * Matricula Consular * U.S. Permanent Resident Card

* Business/Organization Use

* Residential/Personal Use

* U.S. University ID Card * NEXUS Card

4. Name of Applicant 9. Address ID Information for Applicant

4a. Last Name 4b. First Name 4c. Middle Initial 9a. Applicant’s Name

4d. Telephone Number (include area code) 4e. Email Address 9b. Applicant’s Street Home Address

4f. Applicant’s Street Home Address

1,4

9c. City 9d. State 9e. ZIP + 4 9f. Country

4g. City 4h. State 4i. ZIP + 4 4j. Country 9g. Address ID type (check one) — Must Contain the Address in 9b–9f

* U.S. State/Territory/Tribal Driver’s or Nondriver’s ID Card

* Current Lease * Home or Vehicle Insurance Policy

4k. Is applicant a court-ordered protected individual?

* Yes * No

* Mortgage or Deed of Trust * Vehicle Registration Card * Voter Card

If “Yes,” you must attach a copy of the court order.

5. Authorized Individual

10. Photo ID Information for Authorized Individual (if applicable)

5a. Last Name 5b. First Name 5c. Middle Initial 10a. Authorized Individual’s Name 10b. Authorized Individual’s ID Number

5d. Telephone Number (include area code) 5e. Email Address 10c. Issuing Entity 10d. Expiration Date on the ID

5f. Authorized Individual’s Street Home Address

1,6

10e. Photo ID type (check one)

* U.S. State/Territory/Tribal Driver’s or Nondriver’s ID Card

* Uniformed Service ID * Passport * Certicate of Naturalization

5g. City 5h. State 5i. ZIP + 4 5j. Country

* U.S. Access Card * Matricula Consular * U.S. Permanent Resident Card

* U.S. University ID Card * NEXUS Card

6. If Transferring PMB Mail to Another Address

… 11. Address ID Information for Authorized Individual (if applicable)

6a. Street Address Mail Is Transferred To

11a. Authorized Individual’s Name

6b. City 6c. State 6d. ZIP + 4 6e. Country 11b. Authorized Individual’s Street Home Address

6f. Telephone Number (include area code) 6g. Email Address 11c. City 11d. State 11e. ZIP + 4 11f. Country

7. Business/Organization Information

11g. Address ID type (check one) — Must Contain the Address in 11b–11f

7a. Name of Business/Organization 7b. Type of Business

* U.S. State/Territory/Tribal Driver’s or Nondriver’s ID Card

* Current Lease * Home or Vehicle Insurance Policy

* Mortgage or Deed of Trust * Vehicle Registration Card * Voter Card

7c. Business Street Address

12. Exceptions for Additional Recipients of Mail

7d. City 7e. State 7f. ZIP + 4 7g. Country

13a. Signature of Applicant

13b. Date

7h. Telephone Number (include area code) 7i. Place of Registration

14a. Signature of Witness

14b. Date

PS Form 1583, April 2023 (Page 1 of 2) (7530-01-000-9365)

Direct questions to: Retail, Chief Retail and Delivery Ofcer at [email protected].

This form is on the Internet at www.usps.com.

Instructions and Footnotes

1 Include house number, street, and apartment/suite number if applicable.

2 For Business/Organization Use, complete item 7.

3 For Residential/Personal Use, complete a separate PS Form 1583 for each adult using this PMB.

4 Address must match document provided in item 9b.

5 The Applicant authorizes mail to be collected by the individual noted in item 5.

6 Address must match document provided in item 11b.

7 Complete item 6 if the mail addressed to this PMB is to be transferred, mailed, shipped, or emailed to another address.

8 The place of registration is the county and state (if domestic), or the country (if foreign).

9 Two types of identication are required for both the Applicant and, if listed, the Authorized Individual. One ID must be a government-issued photo ID. The

second must conrm the Applicant’s or Authorized Individual’s address listed on this form. The acceptable types of photo ID are listed in items 8e and 10e.

Attach a copy of the photo and address ID documents.

10 Although the driver’s/nondriver’s ID is listed in 8e and 9g as an option for both the Applicant’s photo ID and address ID, it may be used for only one of the IDs

(either photo ID or address ID), not for both.

11 The acceptable types of address verication are listed in items 9g and 11g. Attach a copy of the photo and address ID documents.

12 Although the driver’s/nondriver’s ID is listed in 10e and 11g as an option for both the Authorized Individual’s photo ID and address ID, it may be used for only

one of the IDs (either photo ID or address ID), not for both.

13 For Business/Organization Use: List members who will be receiving mail at this PMB. Each person listed must, upon request, present two forms of valid ID to

the Postal Service.

For Residential/Individual Use: A parent or guardian may receive the mail of a minor by listing the minor’s name — the minor’s ID is not required.

14 By signing this form, the applicant certies the following — for Business/Organization Use, an ofcer must sign the application and provide his or her title:

I certify that all information furnished on this form is accurate, truthful, and complete. I understand that anyone who furnishes false or misleading

information on this form or omits information requested on this form may be subject to criminal and/or civil penalties, including nes and imprisonment.

15 The witness can be the agent, an authorized employee, or a Notary Public.

Denitions:

Agent: The Commercial Mail Receiving Agency (CMRA).

Authorized employee: An employee of the CMRA who is authorized to act

on the CMRA’s behalf.

Authorized individual: A person who is authorized to pick up mail for the

PMB holder.

Agreement: In consideration of delivery of my mail or our rm’s mail to the

agent named on Page 1, the applicant and agent agree: (1) the applicant or

the agent must not le a change of address order with the Postal Service™

upon termination of the agency relationship; (2) the transfer of mail to

another address is the responsibility of the applicant and the agent; (3) all

mail delivered to the agency under this authorization must be prepaid with

new postage when redeposited in the mails; (4) the agent must provide to

the Postal Service all addresses to which the agency transfers mail; and (5)

when any information required on this form changes or becomes obsolete,

the applicant must le an updated application with the agent.

NOTE: The applicant must execute this form in the presence of the agent,

his or her authorized employee, or a notary public. The agent uploads the

original completed signed PS Form 1583 to the Postal Service’s CMRA

Customer Registration Database and retains the completed signed copy at

the CMRA business location. The CMRA copy of PS Form 1583 must at all

times be available for examination by the postmaster (or designee) and the

Postal Inspection Service. The applicant and the agent agree to comply with

all applicable Postal Service rules and regulations relative to delivery of mail

through an agent. Failure to comply will subject the agency to withholding of

mail from delivery until corrective action is taken.

This application may be subject to verication procedures by the Postal

Service to conrm that the applicant resides or conducts business

at the home or business address listed in items 4f or 7c, and that the

identications listed in items 8–11 are valid. The agent must complete items

2a–2e, and items 14a and 14b if necessary (i.e., if the agent is the witness),

and the customer must complete all the other items.

Privacy Act Statement: Your information will be used to administer the

Commercial Mail Receiving Agency (CMRA) application, enrollment, and

fulllment processes, to verify your identity when applying for service via a

CMRA, to ensure proper and secure delivery of mail to the correct recipient,

and to permit delivery of your mail to your authorized agent. Collection

is authorized by 39 USC 401, 403, and 404. Supplying the information is

voluntary, but if not provided, we will not be able to fulll your request for

delivery of mail through an agent. We do not disclose your information

without your consent to third parties, except for the following limited

circumstances: incident to legal proceedings involving the Postal Service;

for law enforcement purposes; to a congressional ofce on your behalf; to

agents or contractors when necessary to fulll a business function; to a

U.S. Postal Service auditor; to labor organizations as required by applicable

law; to government agencies in connection with decisions as necessary;

to agencies and entities for nancial matters; and for customer service

purposes. In addition, information may be disclosed for the purpose of

identifying an address as an address of an agent to whom mail is delivered

on behalf of other persons. However, this specic routine use does not

authorize the disclosure of the identities of persons on behalf of whom

agents receive mail. All routine uses are subject to the following exception:

Information concerning an individual who has led an appropriate protective

court order with the application will not be disclosed except pursuant to the

order of a court of competent jurisdiction and subject to the approval of the

USPS General Counsel. For more information on our privacy policies, visit

www.usps.com/privacypolicy.

Witness my signature and ofcial seal. Notary Public in and for the STATE OF __________________________________,

COUNTY OF _______________________________. On this ______ day of ____________________________, 20______,

the applicant, who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to

this application, appeared before me, and did personally sign the application.

Ofcial Seal:

Signature of Notary Public

____________________________________________________

My commission expires:

__________________________________________, 20________

PS Form

1583, April 2023 (Page 2 of 2) (7530-01-000-9365)

Direct questions to: Retail, Chief Retail and Delivery Ofcer at [email protected].

This form is on the Internet at www.usps.com.