Ps Form 2146 – Fill Out and Use This PDF

Name of Claimant

SSN

Job Title of Claimant

Claimant's Home Address

Claimant's Work Address/Work Phone Number

Date Loss/Damage Occurred

Total Amount of Claim

$

Article(s) for Which Claim is Made

Homeowners

Name & Address of Insurance Company

Insurance

Yes

No

Collision

#Yes

#No

Comprehensive

#Yes

#No

Other (Specify)#:

Has Claim been Filed with Insurance Company?

Yes

#No

Amount of Deductible

If "yes", action taken:

$

If damage/loss result from the negligence of another party, has an attempt

been made#to recover from that party?

Yes

#No

(If "Yes" explain on separate sheet.)

I certify that the damage, loss, or destruction was not caused in whole or in

I make the foregoing claim with full knowledge of the penalties involved for

part by any negligence or wrongful act of the claimant, or his agent or employ-

willfully making a false claim. (US Code, Title 18, Section 287, provides for

ee. All articles listed on this sheet (or additional sheets made part of this

a maximum fine of $10,000 or imprisonment for 5 years, or both.)

form) have been privately purchased and are not government property. No

I hereby assign to the United States to the extent of any payment of this

previous claim has been made to the government for the property for which

claim accepted by me all my right, title, and interest in and to any claim that I

this claim is made (except as explained on the attached sheet).

This claim

may have against any insurer or other party, arising out of the damage, loss,

does not duplicate any made under the Workman's Compensation Program.

or destruction to the property described on this form and will, upon request,

If any of the property for which claim is made is later recovered, claimant

furnish such evidence as may be required to enable the United States to en-

agrees to give written notice immediately to the US Postal Service.

force such claim.

Date of Claim

Claimant's Signature

1. Was Claim Submission Timely?

Yes

No

(If "no", explain.)

Is Part 1 Complete?

#Yes

No

Is Part 2 Complete?

Yes

#No

2.

Was possession of lost/damaged property reasonable, proper, and necessary to the performance of the employee's employment?

#Yes

#No

(If "no", explain.)

3.

Was there any negligence on the part of the employee which contributed to the loss/damage?

#Yes

#No

(If "no", explain.)

5. Based on the above, do you recommend payment?

#Yes

#No

Date of Report

Finance No. of Postal Installation

Signature and Title of Supervisor