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Claimant for Reduced Price

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: __________________________


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 for Reduced Price | Free Sample Printable Blank Legal Forms

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