CXHelp@forever21.

com Affidavit Claim Form

What is the problem? My Item/Order is: Lost All Contents Missing Some Contents Missing

Forever 21 Order Number: Order Date:

Shipping Carrier: USPS FedEx Other Tracking Number:

Name & Address:

First Name MI Last Name

Business Name (Use only if the mailer is a company)

Address Line 1 (Number, Street)

Address Line 2 (Suite / Apartment Number)

City

State Province (If applicable) ZIP+4 or Postal Code

Urbanization or Country Telephone Number

Email Address

Description of Lost or Item Codes: 01 Gift Cards 02 Jewelry 03 Clothing 04 Other

Item Code
Missing Contents Describe Contents & Product Code Below (See Quantity Price

1
List one item per line. 2

TOTAL AMOUNT CLAIMED FOR ITEMS LISTED ABOVE .

Forever 21 will attempt to track and locate your order and if found we will reship your order to you. Please allow up to 5 business days for the investigation to be
completed. Thank you for your patience.
Note
If your order was shipped via United States Postal Service and your order has not been delivered, your package may be at your local Post Office. We suggest contacting your
local post office or requesting a redelivery of your package online at www.usps.com/redelivery.

Required
Did you contact your local post office or shipping carrier for your package? Yes No
Information Did you receive a notice from the post office or shipping carrier? Yes No
Certification
I certify that all information furnished on this form is accurate, truthful, and complete, and that I understand that anyone who furnishes false or misleading information on
Please sign, date
this form or who omits information requested on this form may be subject to criminal and/or civil penalties, including fines and imprisonment.
& enter your
telephone Customer Submitting Claim: Mailer Addressee
number. Signature of Customer Filing the Claim Date Signed (MM/DD/YYYY) Telephone Number

EMAIL THE COMPLETED AND SIGNED FORM TO CXHelp@FOREVER21.COM within 5 business days.