Key

Form 1583 Sample Guide = Business Fields

= Complete fields in order to avoid
mistakes requiring re-notarization

Date Mailbox Opened Applicant's Legal Name - Photo ID Number

As Listed on IDs

State or Agency Photo ID Expiration Date

Applicant's iPostal1 Address that Issued Photo ID
+ Unique Mailbox # Select One
1048 48071
Select One (For USPS purposes
only. Selection will
not affect your plan

Applicant's Legal Name - As Listed on IDs Applicant's Legal Name - As Listed on IDs

Applicant's Phone Number Applicant's Email Address Address must match the
Address ID (9g), NOT the
Photo ID
Address must match the Detroit 48205
Address ID (9g), NOT the
Photo ID Select One
48205 U.S 1

N/A N/A N/A N/A N/A

N/A Block 5 N/A N/A N/A

Block 10
(Not applicable) (Not applicable)
N/A N/A

N/A N/A N/A N/A

N/A N/A
Block 6 Block 11
N/A (Not applicable) N/A N/A N/A (Not applicable)

N/A N/A N/A N/A N/A N/A

N/A
[Business Business/Organization Name Business Type
Custom]ers
Only
Enter Business Address - Minor Children (Under 18yrs) only
As Registered
Madison Heights MI 48071 U.S Applicant's Signature Business Title Date

Business Phone Number Domestic: Enter County & State Agent/Notary's Signature Date
Foreign: Enter Country

UNREGISTERED?
Business Address: Address in 2a-e can be used
Place of Registration: Enter N/A
(One business name per account)
 Maxine Jones 9 Oct 23

If notarizing with a Notary Public, ensure this section is completed

 Application for Delivery of Mail Through Agent
See Reverse for Instructions, Definitions, Agreement Terms, and the Privacy Act Statement.
1. Private Mailbox (PMB) Information 8. Photo ID Information for Applicant9
1a. Date PMB Opened 1b. Date PMB Closed 8a. Applicant’s Name 8b. Applicant’s ID Number

September 10, 2023 Calvin Jones J520108609143

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 Delivery1 2b. PMB # 01-09-023
February 24, 2027
27733 John R Road 1048
2c. City 2d. State 2e. ZIP + 4® 8e. Photo ID type (check one)

Madison Heights MI 48071 *

X U.S. State/Territory/Tribal Driver’s or Nondriver’s ID Card
10

* Uniformed Service ID * Passport * Certificate of Naturalization

3. Type of Service Requested * U.S. Access Card * Matricula Consular * U.S. Permanent Resident Card
*
X Business/Organization Use 2
* Residential/Personal Use 3
* U.S. University ID Card * NEXUS Card
4. Name of Applicant 9. Address ID Information for Applicant11
4a. Last Name 4b. First Name 4c. Middle Initial 9a. Applicant’s Name

Jones Calvin Calvin Jones

4d. Telephone Number (include area code) 4e. Email Address 9b. Applicant’s Street Home Address1
[email protected]
+15866968203 14835 Seymour st
4f. Applicant’s Street Home Address1,4 9c. City 9d. State 9e. ZIP + 4 9f. Country

14835 Seymour st Detroit MI 48205 US

4g. City 4h. State 4i. ZIP + 4 4j. Country 9g. Address ID type (check one) — Must Contain the Address in 9b–9f
Detroit MI 48205 US *
X U.S. State/Territory/Tribal Driver’s or Nondriver’s ID Card
10

* Current Lease * Home or Vehicle Insurance Policy

4k. Is applicant a court-ordered protected individual? * Yes *
X No * Mortgage or Deed of Trust * Vehicle Registration Card * Voter Card
If “Yes,” you must attach a copy of the court order.
5. Authorized Individual5 10. Photo ID Information for Authorized Individual (if applicable)9
5a. Last Name 5b. First Name 5c. Middle Initial 10a. Authorized Individual’s Name 10b. Authorized Individual’s ID Number

N/A N/A N/A N/A N/A

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

N/A N/A N/A N/A

5f. Authorized Individual’s Street Home Address 1,6
10e. Photo ID type (check one)

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

12

* Uniformed Service ID * Passport * Certificate of Naturalization

5g. City 5h. State 5i. ZIP + 4 5j. Country
* U.S. Access Card * Matricula Consular * U.S. Permanent Resident Card
N/A N/A N/A N/A * U.S. University ID Card * NEXUS Card
6. If Transferring PMB Mail to Another Address7… 11. Address ID Information for Authorized Individual (if applicable)11
6a. Street Address Mail Is Transferred To1 11a. Authorized Individual’s Name

N/A N/A
6b. City 6c. State 6d. ZIP + 4 6e. Country 11b. Authorized Individual’s Street Home Address1

N/A N/A N/A N/A N/A

6f. Telephone Number (include area code) 6g. Email Address 11c. City 11d. State 11e. ZIP + 4 11f. Country
N/A N/A N/A N/A N/A N/A
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
12

* Current Lease * Home or Vehicle Insurance Policy

Committed Cargo Logistics LLC Transportation
* Mortgage or Deed of Trust * Vehicle Registration Card * Voter Card
7c. Business Street Address 1
12. Exceptions for Additional Recipients of Mail13

27733 John R Road #1048

7d. City 7e. State 7f. ZIP + 4 7g. Country 13a. Signature of Applicant14 13b. Date
Madison Heights MI 48071 US 27733 John R Road #1048 Madison Heights, MI 48071
7h. Telephone Number (include area code) 7i. Place of Registration 8
14a. Signature of Witness15 14b. Date
5866968203 Oakland MI

PS Form 1583, April 2023 (Page 1 of 2) (7530-01-000-9365) Direct questions to: Retail, Chief Retail and Delivery Officer 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 identification are required for both the Applicant and, if listed, the Authorized Individual. One ID must be a government-issued photo ID. The
second must confirm 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 verification 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 certifies the following — for Business/Organization Use, an officer 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 fines and imprisonment.
15 The witness can be the agent, an authorized employee, or a Notary Public.

Definitions: at the home or business address listed in items 4f or 7c, and that the
Agent: The Commercial Mail Receiving Agency (CMRA). identifications listed in items 8–11 are valid. The agent must complete items
Authorized employee: An employee of the CMRA who is authorized to act 2a–2e, and items 14a and 14b if necessary (i.e., if the agent is the witness),
on the CMRA’s behalf. and the customer must complete all the other items.
Authorized individual: A person who is authorized to pick up mail for the
PMB holder. Privacy Act Statement: Your information will be used to administer the
Commercial Mail Receiving Agency (CMRA) application, enrollment, and
Agreement: In consideration of delivery of my mail or our firm’s mail to the fulfillment processes, to verify your identity when applying for service via a
agent named on Page 1, the applicant and agent agree: (1) the applicant or CMRA, to ensure proper and secure delivery of mail to the correct recipient,
the agent must not file a change of address order with the Postal Service™ and to permit delivery of your mail to your authorized agent. Collection
upon termination of the agency relationship; (2) the transfer of mail to is authorized by 39 USC 401, 403, and 404. Supplying the information is
another address is the responsibility of the applicant and the agent; (3) all voluntary, but if not provided, we will not be able to fulfill your request for
mail delivered to the agency under this authorization must be prepaid with delivery of mail through an agent. We do not disclose your information
new postage when redeposited in the mails; (4) the agent must provide to without your consent to third parties, except for the following limited
the Postal Service all addresses to which the agency transfers mail; and (5) circumstances: incident to legal proceedings involving the Postal Service;
when any information required on this form changes or becomes obsolete, for law enforcement purposes; to a congressional office on your behalf; to
the applicant must file an updated application with the agent. agents or contractors when necessary to fulfill a business function; to a
U.S. Postal Service auditor; to labor organizations as required by applicable
NOTE: The applicant must execute this form in the presence of the agent, law; to government agencies in connection with decisions as necessary;
his or her authorized employee, or a notary public. The agent uploads the to agencies and entities for financial matters; and for customer service
original completed signed PS Form 1583 to the Postal Service’s CMRA purposes. In addition, information may be disclosed for the purpose of
Customer Registration Database and retains the completed signed copy at identifying an address as an address of an agent to whom mail is delivered
the CMRA business location. The CMRA copy of PS Form 1583 must at all on behalf of other persons. However, this specific routine use does not
times be available for examination by the postmaster (or designee) and the authorize the disclosure of the identities of persons on behalf of whom
Postal Inspection Service. The applicant and the agent agree to comply with agents receive mail. All routine uses are subject to the following exception:
all applicable Postal Service rules and regulations relative to delivery of mail Information concerning an individual who has filed an appropriate protective
through an agent. Failure to comply will subject the agency to withholding of court order with the application will not be disclosed except pursuant to the
mail from delivery until corrective action is taken. order of a court of competent jurisdiction and subject to the approval of the
This application may be subject to verification procedures by the Postal USPS General Counsel. For more information on our privacy policies, visit
Service to confirm that the applicant resides or conducts business www.usps.com/privacypolicy.

Witness my signature and official seal. Notary Public in and for the STATE OF __________________________________, Official Seal:

COUNTY OF _______________________________.
Wayne On this ______
9 day of ____________________________,
October 20______,
23
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.

Signature of Notary Public My commission expires:

____________________________________________________ __________________________________________,
November 20________
2023

PS Form 1583, April 2023 (Page 2 of 2) (7530-01-000-9365) Direct questions to: Retail, Chief Retail and Delivery Officer at [email protected].
This form is on the Internet at www.usps.com.®