MAGAZINE RETURNS AFFIDAVIT

Customer Name: Account Number:
BZ
Magazine Title BIPAD # Issue Date Qty
Submitted by:
Your Title:
E-mail Address:
Today's Date:
By submission of this form, I certify that the title issue and quantity listed hereon are true and correct. I further certify that these periodicals have been destroyed so as to render them unusable as reading matter as follows; compacting and water soaking.