SAMPLE FORM: FOR NOTARY REFERENCE

PLEASE ENSURE ALL NOTARY INSTRUCTIONS IN BLUE ARE REVIEWED.

PLEASE ALSO REVIEW ALL NOTES IN RED WITH SIGNER.

UTILITY BILLS ARE NOT ACCEPTED.

Date

Applicant’s iPostal1 address with unique Box #

Applicant’s LEGAL name – As listed on ID.
And/Or Business name

Name of Mail Center/Store

Applicant’s iPostal1 address Must say ‘YES’ or have applicant’s signature Line 7a-7e:
Line 6: with unique Box # Applicant’s
Primary HOME address.
Applicant’s This address
Legal name should be listed
must Applicant’s LEGAL Name – As Listed on Gov’t ID on at least one
match IDs Applicant’s HOME Address - As Listed on 2nd ID of the two IDs
provided. provided by the
primary
applicant.
Line 8a-8b: Cannot be a PO
Must indicate IDENTIFICATION #1 BOX.
Applicant’s 2 Business Name/Entity. Otherwise, N/A
IDs – Include
ID Numbers IDENTIFICATION #2 IF Business
and EXP. date
if applicable. name listed on
Cannot be #9, Fields 10a-
blank. 11 are required.
Business Type/Description

Applicant may list minor child(ren) or a spouse in this field. (First and Last Name required) Please
indicate if any name listed in a minor. NOTE: iPostal1 will require 2 valid, acceptable IDs from the
spouse to be provided, which should be uploaded through your iPostal1 account.

IF COMPANY IS A CORPORATION, this field is

Line 15: Cannot required. (Names and addresses are required, IF BUSINESS IS REGISTERED, this field is
be blank. Must but IDs are not needed) Otherwise, N/A required. Otherwise, N/A
include notary’s
signature and Line 16:
seal/stamp OR Applicant
say ‘See must sign.
Attached Cannot be
Certificate’ with blank.
the notary’s
signature and
seal/stamp on
the final page.
UTILITY BILLS ARE NOT ACCEPTED.
United States Postal Service®
Application for Delivery of Mail Through Agent 1. Date
See Privacy Act Statement on Reverse February 18, 2023
In consideration of delivery of my or our (firm) mail to the agent named below, the addressee and agent agree: (1) the addressee or
the agent must not file a change of address order with the Postal Service™ upon termination of the agency relationship; (2) the
transfer of mail to another address is the responsibility of the addressee and the agent; (3) all mail delivered to the agency under this
authorization must be prepaid with new postage when redeposited in the mails; (4) upon request the agent must provide to the Postal
Service all addresses to which the agency transfers mail; and (5) when any information required on this form changes or becomes
obsolete, the addressee(s) must file a revised application with the Commercial Mail Receiving Agency (CMRA).
NOTE: The applicant must execute this form in duplicate in the presence of the agent, his or her authorized employee, or a notary
public. The agent provides the original completed signed PS Form 1583 to the Postal Service and retains a duplicate completed signed
copy at the CMRA business location. The CMRA copy of PS Form PS 1583 must at all times be available for examination by the
postmaster (or designee) and the Postal Inspection Service. The addressee and the agent agree to comply with all applicable Postal
Service rules and regulations relative to delivery of mail through an agent. Failure to comply will subject the agency to withholding of
mail from delivery until corrective action is taken.
This application may be subject to verification procedures by the Postal Service to confirm that the applicant resides or conducts
business at the home or business address listed in boxes 7 or 10, and that the identification listed in box 8 is valid.
2. Name in Which Applicant's Mail Will Be Received for Delivery to Agent. 3a.Address to be Used for Delivery (Include PMB or # sign.)
(Complete a separate PS Form 1583 for EACH applicant. Spouses may
complete and sign one PS Form 1583. Two items of valid identification apply
to each spouse. Include dissimilar information for either spouse in appropriate 1342 NM 333 STE C #1486 PMB 1044
box.) 3b. City 3c. State 3d. ZIP + 4®
Diana Romero Rodriguez Tijeras ALNM 87059-8221
5. This authorization is extended to include restricted delivery mail for the
4. Applicant authorizes delivery to and in care of: undersigned(s):
a. Name
YES
One Stop Office
b. Address (No.,
street, apt./ste. no.)
1342 NM 333 STE C #1486 PMB 1044
c. City d. State e. ZIP + 4
Tijeras AL
NM 87059-8221
6. Name of Applicant 7a. Applicant Home Address (No., street, apt./ste. no)
Diana Romero Rodriguez Del arroyo # 2216, fracc Sendero de las moras, Tlajomulco de Z
8.Two types of identification are required. One must contain a photograph of 7b. City 7c. State 7d. ZIP + 4
the addressee(s). Social Security cards, credit cards, and birth certificates
are unacceptable as identification. The agent must write in identifying
Tlajomulco de zuniga AL 45645
information. Subject to verification. 7e. Applicant Telephone Number (Include area code)
a.
9. Name of Firm or Corporation
Passport Amsadi Metanoia .llc
b. 10a. Business Address (No., street, apt./ste. no)
1342 NM 333 STE C #1486 PMB 1044
Non-driver's identification card 10b. City 10c. State 10d. ZIP + 4
Tijeras AL
NM 87059-8221
Acceptable identification includes: valid driver's license or state non-driver's 10e. Business Telephone Number (Include area code)
identification card; armed forces, government, university, or recognized
corporate identification card; passport, alien registration card or certificate of 2146280440
naturalization; current lease, mortgage or Deed of Trust; voter or vehicle 11. Type of Business
registration card; or a home or vehicle insurance policy. A photocopy of your
identification may be retained by agent for verification.
Marketing
12. If applicant is a firm, name each member whose mail is to be delivered. (All names listed must have verifiable identification. A guardian must list the names
of minors receiving mail at their delivery address.)

13. If a CORPORATION, Give Names and Addresses of Its Officers 14. If business name (corporation or trade name) has been registered, give
name of county and state, and date of registration.

Warning: The furnishing of false or misleading information on this form or omission of material information may result in criminal sanctions (including fines and
imprisonment) and/or civil sanctions (including multiple damages and civil penalties).
15. Signature of Agent/Notary Public 16. Signature of Applicant (If firm or corporation, application must be signed
by officer. Show title.)

PS Form 1583, December 2004 (Page 1 of 2) (7530-01-000-9365) This form on Internet at www.usps.com®
 Privacy Act Statement: Your information will be used to authorize the delivery of your mail to the designated
addressee as your agent. Collection is authorized by 39 USC 401, 403, and 404. Providing the information is
voluntary, but if not provided, we cannot provide this service to you. We do not disclose your information without your
consent to third parties, except for the following limited circumstances: to a congressional office on your behalf; to
financial entities regarding financial transaction issues; to a USPS® auditor; to entities, including law enforcement, as
required by law or in legal proceedings; to contractors and other entities aiding us to fulfill the service; and for the
purpose of identifying an address as an address of an agent who receives mail on behalf of other persons. Information
concerning an individual who has filed an appropriate protective court order with the postmaster will not be disclosed
except pursuant to court order. For more information on our privacy policies, see our privacy link on usps.com®.

PS Form 1583, December 2004 (Page 2 of 2) (7530-01-000-9365)