USPS 1583 Form - officeLOCALE

1. Private Mailbox (PMB) Information

1a. Date PMB Opened

2a. Street Address to be Used for Delivery¹

275 E. Hill crest Drive, Suite 160-

2b. PMB # or Suite Number

2c. City

2d. State

2e. ZIP + 4^®

3. Type of Service Requested

Business/Organization Use² Residentail/Personal Use³

4. Name of Applicant

4a. Last Name

4b. First Name

4c. Middle Initial

4d. Telephone Number (include area code)

4e. Email Address

4f. Applicant's Street Address¹ ⁴

4g. City

4h. State

4i. ZIP + 4

4j. Country

4k. Is applicant a court ordered protected individual?If "Yes," you must attach a copy of the court order.

Yes No

Upload your photo ID

5. Authorized Individual⁵ - Put N/A in all fields that don't apply

5a. Last Name

5b. First Name

5c. Middle Initial

5d. Telephone Number (include area code)

5e. Email Address

5f. Authorized Individual's Street Address¹ ⁶

5g. City

5h. State

5i. ZIP + 4

5j. Country

6. If Transferring PMB Mail to Another Address¹...

6a. Street Address Mail Is Transferred To¹

6b. City

6c. State

6d. ZIP + 4

6e. Country

6f. Telephone Number (include area code)

6g. Email Address

7. Business/Organization Information

7a. Name of Business/Organization

7b. Type of Business

7c. Business Street Address¹

7d. City

7e. State

7f. ZIP + 4

7g. Country

7h. Telephone Number (include area code)

7i. Place of Registration⁸

8. Photo ID Information for Applicant⁹

8a. Applicant's Full Name

8b. Applicant's ID Number

8c. Issuing Entity

8d. Expiration Date on the ID

8e. Photo ID type (check one)

9. Address ID information for Applicant¹¹

9a. Applicant's Full Name

9b. Applicant's Street Home Address¹

9c. City

9d. State

9e. ZIP + 4

9f. Country

9g. Address ID type (check one) - Must Contain the Address in 9b-9f

10. Photo ID Information for Authorized Individual (if applicable)⁹

10a. Authorized Individual's Name

10b. Authorized Individual's ID Number

10c. Issuing Entity

10d. Expiration Date on the ID

10e. Photo ID type (check one)

10. Photo ID Information for Authorized Individual (if applicable)¹¹

11a. Authorized Individual's Name

11b. Authorized Individual's Street Home Address¹

11c. City

11d. State

11e. ZIP + 4

11f. Country

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

12. Exceptions for Additional Recipients of Mail¹³

13a. Signature of Applicant¹⁴

13b. Date

14a. Signature of Witness¹⁵

14b. Date

STATE OF

COUNTY OF

On this

day of

Witness Year 20 _ _

Signature of Notary Public

My commission expires

Signature Year 20