B&H Photo & Video Customer Service Dept, 420 Ninth Ave. NY, NY 10001 Phone: 212-239-7765 ~ (800)221-5743 Fax: 212-502-9426 ~ (866)521-7375 E-mail: ord-status@bhphotovideo.com --------------------------- | USP CLAIM FORM AFFIDAVIT | --------------------------- Order Number: 301827470 Claim Number: 15516 Date of Shippment: 2010-06-21 Qty Item(s) Value(s) Tracking Number(s) --- ------------------------------------ --------- ---------------------- 1 VEB612 6" EBOOK READER $149.00 37000063882 --- ------------------------------------ --------- ---------------------- I, ____________________ acknowlege that the above item(s) Shipped to: *****************мой адрес***************** ************ were lost/damaged in transit to me. I hereby authorize B&H to file a claim with their insurance company in order to resolve this matter. I affirm that the above information is true, and realize that any fraudulent claims will make the consignee liable for any prosecution for mail fraud under Federal Criminal Code. Please check one of the following: ___ I would like a replacement of merchandise. ___ I would like a refund. Thank You, x________________________ Print____________________ Date:____________________ P.S. According to our Insurance Company Regulations, it must be past 30 days from the Shipping Date on Domestic shipments, and past 45 days from the Shipping Date for International shipments, for B&H to file a claim with them and have the customer sign the above Affidavit.