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Y filed for (check one): Date filed: Non delivery Shortage Damage Claim Payable to: UPS Bill of Lading/Air Waybill No: Company Name UPS Bill of Lading/Air Waybill date: Address UPS Order No.: Date: City/Town & State & Country Claimant Reference No.: Confirmation Number : Shipper Consignee Address Zip / Postal Code Address City/Town & State & Country Zip / Postal Code City/Town & State & Country Zip / Postal Code CLAIM MUST BE SUPPORTED BY A DETAILED STATEMENT SHOWING HOW TH.

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