PCGS CURRENCY Submission Form Submission # 9007075
P.O. Box 9458, Newport Beach, CA 92658
  800-447-8848 www.pcgscurrency.com  
  email: info@pcgscurrency.com Fax: 949-833-7660  

Note: You must be a current PCGS-C Collectors Club member or an authorized PCGS Currency Dealer to submit currency for grading. If you are not a current Collector's Club member, please contact Customer Service at 800-447-8848 for information on joining.
PACKAGE INFORMATION: (Customer Must Provide)
1. Total number of submissions (orders) included in this package: __________
2. This submission (order) is _______ of _______ (e.g. 1 of 3, 2 of 3, 3 of 3, etc.)
3. Total number of notes included in this package (all orders): __________
Member:

Member #

RETURN SHIPPING ADDRESS

Name:

Address:

City, State, Zip:

Phone:

Email:
Alternate Return Carrier (choose one)
If using a method other than USPS Registered Mail, you must provide your own acct.# and insurance coverage.
Pick Up (by approval only)
USPS Express Mail
FedEx
Acct # ________________
Insurance Limit (Required) ___________
Sat Delivery   Priority
Standard   2-Day
3-Day   Ground
Signature Required _____ Yes   _____ No
PCGSC USE ONLY


Order # _______________

Box _______________

Item # _______________

Inv. Type Code __________

Date Received __________
A. SERVICE LEVEL: Choose one per submission form
ULTRA RARITY SERVICE
(2 business days; unlimited value) 		$375
RARITY SERVICE
(2 business days; max value $100,000 per note) 		$250
WALKTHROUGH
(2 business days; max value $50,000 per note) 		$125
EXPRESS
(5 business days; max value $20,000 per note) 		$75
REGULAR
(15 business days; max value $5,000 per note)
  LARGE SIZE, COLONIAL, CANADIAN $40
  SMALL SIZE, FRACTIONAL, CSA, OBSOLETES $35
  MODERN SMALL SIZE*, MPC $30
ECONOMY
(Approx. 20-30 business days; max value $1,000 per note; min 5 notes)
  LARGE SIZE, COLONIAL, CANADIAN $26
  SMALL SIZE, FRACTIONAL, CSA, OBSOLETES $22
  MODERN SMALL SIZE*, MPC $18
BULK
(Max value $500; min 25 notes with all the same Friedberg number)
  LARGE SIZE, COLONIAL, CANADIAN $20
  SMALL SIZE, FRACTIONAL, CSA, OBSOLETES $16
  MODERN SMALL SIZE*, MPC $12
REHOLDER
(approx. 5 business days) 		$6
RECONSIDERATION
(approx. 5 business days) 		$25
Other $ _____
* Modern series 1957 to present
Please remember that show blackout dates apply to all service levels
B. GRADING FEE CALCULATION
 
____________ X ____________
# of notes   grading fee
 
= $ _____
YOU ARE RESPONSIBLE FOR RETURN SHIPPING FEES

 
C. SHIPPING COST (per submission form)
All packages are returned by Registered Mail
  (Shipping & Handling based on the number of notes and declared value from the chart below. Orders cannot be combined for shipping purposes.) = $ _____
 
D. TOTAL CHARGES (Add lines B and C) = $ _____
 
E. METHOD OF PAYMENT
All fees must be paid in advance before PCGS-C can process your order. Failure to include delivery or insurance fees will delay your order.
MC / VISA     AMEX (max. $2,500/mo.)     CASH   
 CHECK # _________    MONEY ORDER # ________   
 
Credit Card No.  __________________________________
 
Exp. Date  ___________
 

Cardholder Signature 
__________________________________
 

Billing Address:
If paying by credit card, please provide billing address for card or your order may be delayed.
 

Address 
__________________________________
 

City/State/Zip/Country
__________________________________
 
  QTY FR NO. SERIES DENOM. TYPE VARIETY SERIAL NO. DECLARED VALUE
0 1 1531* 1934D $5 SILVER CERTIFICATE WIDE II *14141414A $5,000
1                
2                
3                
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20                

Order will not be processed without signature
I HAVE READ AND AGREE TO THE PCGS-C GRADING TERMS AND PROCEDURES ON THE BACK OF THIS FORM. I ACCEPT FULL RESPONSIBILITY FOR COMPLETELY AND ACCURATELY FILLING OUT THE SUBMISSION FORM.
AUTHORIZED SIGNATURE REQUIRED _______________ DATE _______
Order will not be processed without signature
 
TOTAL DECLARED VALUE (Required):

$ __________
 

INSTRUCTIONS (Please read carefully. Following these directions can help expedite your order.)
  1. Please print your name and member or dealer number in the space provided.
  2. Clearly write return Shipping Address, Phone Number, and Email Address.
  3. Place each note in a new Mylar sleeve with the submission number and line number listed. Do not send notes with the holder closed with tape, staples, screw-type plastic holders, or in any other manner.
  4. List each note description on the lines above. For multiple notes of the same date, denomination, Friedberg number, type and variety, you may list the total quantity and enter them on one line. Indicate an Insured Value for each note. In the case of multiple notes on one line, list the Insured Value as a total of all notes on that line.
  5. Select the Type of Submission and Service Level desired. Only ONE Type of Submission, at ONE Service Level is permitted per submission form.
  6. Calculate the Grading Fees and Shipping Cost (refer to chart below). You are required to provide return shipping for EACH order. All packages are returned via USPS Registered Mail. Please note this shipping and handling cost covers return shipments from PCGS CURRENCY only. Please remit the proper fees. DO NOT SEND POSTAGE STAMPS for the return of your package.
  7. Mark Method of Payment and include a check, money order or credit card payment. You must include payment or your order will not be processed.
  8. Read the terms and procedures below and sign and date the bottom of the submission form.
  9. Package Information (required) - Be sure to completely fill out this information.
  10. Tear off and retain the gold copy for your records.
  11. Package your notes and this submission form carefully. To validate the Guaranteed Service, the name of service must be clearly marked on the outside of the package. This will help expedite the process of your order.
  12. All packages must be shipped via Registered Mail or Express mail to PCGS-C, PO Box 9458, Newport Beach, CA 92658. Or you may ship via Federal Express (please contact customer service for the FedEx address). You are responsible for insurance coverage on packages to PCGS CURRENCY.
  13. Note all terms, conditions, services and fees are subject to change. Turnaround times do not include mailing time and reflect business days.
  14. Days during which PCGS CURRENCY is accepting submissions or is performing on-site grading at shows will not be considered business days. Please call Customer Service or visit www.pcgscurrency.com for the latest show schedule.
U.S. POSTAGE AND HANDLING RATE CHART
Over $150,000
call for rates
Declared Value
No. Of Notes $0 - $100 $101 - $1,000 $1,001 - $5,000 $5,001 - $10,000 $10,001 - $25,000 $25,001 - $50,000 $50,001 - $100,000 $100,001 - $150,000
1-5 $13.11 $15.61 $20.41 $26.41 $44.41 $69.96 $123.76 $178.76
6-20 $16.40 $18.90 $23.70 $29.70 $47.70 $73.25 $127.05 $182.05
21-50 $18.35 $20.85 $25.65 $31.65 $49.65 $75.20 $129.00 $184.00
51-99 $22.90 $25.40 $30.20$36.20 $54.20 $79.75 $133.55 $188.35
100= .11 per note + $10.80 $13.30 $18.10 $24.10 $42.10 $67.65 $121.45 $176.45
$25,001+ = $42.10 + $1.20 Per $1,000 Over
 
INTERNATIONAL POSTAGE AND HANDLING RATE CHART
Canada Europe Pacific Rim (Mexico Included)
up to 10 notes $28.95 up to 10 notes $30.95 up to 10 notes $30.95
11-20 notes $32.25 11-20 notes $35.50 11-20 notes $33.50
21-30 notes $35.50 21-30 notes $39.75 21-30 notes $37.75
31-40 notes $38.75 31-40 notes $44.00 31-40 notes $42.00
41-60 notes $44.00 41-60 notes $48.25 41-60 notes $46.25
(Over 60 - 63ยข per note) (Over 60 - $0.70 per note) (Over 60 - $0.67 per note)


CUSTOMER BILL OF RIGHTS

Each customer of a PCGS CURRENCY-authorized dealer is entitled to the following rights:
  1. WRITTEN RECEIPT. When the Customer submits currency to the authorized dealer for grading by PCGS CURRENCY, the authorized dealer will provide the Customer with a receipt identifying the submitted currency.
  2. PROMPT SUBMISSION FOR GRADING. The items will then be delivered to PCGS CURRENCY within ten (10) days after the Customer delivers the coins to the authorized dealer.
  3. PROOF OF SUBMISSION. The Customer is entitled to receive within fifteen (15) days after the Customer delivers the currency to the authorized dealer, a copy of the PCGS CURRENCY invoice form prepared by the authorized dealer for submission to PCGS CURRENCY.
  4. PROMPT RETURN AFTER GRADING. The authorized dealer will promptly return the Customer's graded and holdered items to the Customer within five (5) days after the authorized dealer receives them from PCGS CURRENCY, unless directed otherwise by the Customer.
  5. CAREFUL HANDLING. The Customer's coins will be returned to the Customer in the same condition they were in when the Customer delivered them to the authorized dealer.
  6. GUARANTEED GRADE AND AUTHENTICITY. As an owner of the PCGS CURRENCY graded item, the Customer will have the benefit of PCGS CURRENCY'S Guarantee of Grade and Authenticity and each PCGS CURRENCY authorized dealer will accept the grades assigned to the items by PCGS CURRENCY.
  7. FAIR MARKET PRICES. The Customer can call PCGS at 1-800-447-8848 to report any instance in which an authorized dealer, in offering to buy a PCGS CURRENCY item from the Customer, attempts to justify a lower than market purchase or bid price for the PCGS CURRENCY item on the basis of allegedly improper grading by PCGS CURRENCY, or provide the Customer with an unreasonably low purchase or bid price for the PCGS CURRENCY item (with or without any allegation relating to PCGS CURRENCY'S grading of the item).
  8. PRODUCT RELIABILITY. In the event that PCGS CURRENCY develops and uses different currency holders, each authorized dealer will treat and deal with all PCGS CURRENCY items without any distinction based on the type of holder.
  9. COURTEOUS, HONEST SERVICE. Each authorized dealer will at all times give the Customer prompt, courteous and efficient service, and, in all of the authorized dealer's transactions with the Customer, will observe the highest standards of honesty, integrity, fair dealing and ethical conduct.

PCGS CURRENCY GRADING TERMS AND PROCEDURES
  1. PCGS CURRENCY will endeavor to grade items within the time frame, if any, offered as part of a PCGS CURRENCY grading service. However, PCGS CURRENCY will have no liability whatsoever to the Customer for incidental or consequential damages due to PCGS CURRENCY's failure to grade any item within any time frame. All days are business days.
  2. PCGS CURRENCY will not grade items which, in the opinion of PCGS CURRENCY, bear evidence of significant alteration, unstable paper quality or similar impairments, or are of questionable authenticity. In the event PCGS CURRENCY rejects any item for grading in accordance with PCGS CURRENCY's current grading standards and procedures, PCGS CURRENCY shall not refund the fee paid by Customer.
  3. Grading involves individual judgments that are subjective and require the exercise of professional opinion, which can change from time to time. Therefore, PCGS CURRENCY makes no warranty or representation and shall have no liability whatsoever to the Customer for the grade assigned by PCGS CURRENCY to any item, except pursuant to PCGS CURRENCY's guarantee resubmission, re-verification or regrade service as in effect from time to time.
  4. PCGS CURRENCY will exercise reasonable care in handling items submitted for grading, regrading or reholdering. However, if PCGS CURRENCY determines that the customer's item was lost or damaged while in PCGS CURRENCY's possession, the customer will be compensated in accordance with PCGS CURRENCY's standard procedures and not necessarily based upon the insured value Customer assigned to the item.
  5. Customer must inspect all items immediately upon receipt and PCGS CURRENCY disclaims any liability for damage or discrepancies (such as errors pertaining to the description of the item) unless reported to PCGS CURRENCY within five (5) days of customer's receipt of the item(s). Customer agrees to return any incorrectly described item to PCGS CURRENCY upon request for correction and agrees to indemnify and hold PCGS CURRENCY harmless from any and all losses and/or claims caused by the circulation or sale of any incorrectly describeditemcoin. Repeated failure to report such errors may cause suspension or expulsion of membership from the authorized PCGS CURRENCY Dealer Network.
  6. Customer agrees (a) to pay PCGS CURRENCY all fees and other charges when due; (b) that any delinquent balances shall accrue interest at the rate of 10% per year until paid; and (c) that PCGS CURRENCY shall have a security interest in the items submitted, as well as in any other property of customer in the possession of PCGS CURRENCY or its affiliates, to secure payment thereof.
  7. PCGS CURRENCY shall have no liability whatsoever to the customer, for any personal injury or damage to any item, or otherwise, resulting from the breaking open of a PCGS CURRENCY item holder. PCGS CURRENCY shall have no liability whatsoever to the customer for any damage to any item that PCGS CURRENCY can reasonably demonstrate occurred while not in the custody or control of PCGS CURRENCY.
  8. Except as expressly set forth herein, PCGS CURRENCY disclaims any and all warranties, express or implied, regarding PCGS CURRENCY goods and services including the warranties of merchantability and fitness for a particular purpose.
  9. If items are being submitted for a third party, Dealer certifies that the party has been shown the Customer Bill of rights and PCGS CURRENCY Grading Terms and Procedures. Dealer certifies that the third party has agreed and accepted the PCGS CURRENCY Grading Terms and Procedures and has signed the document where indicated. Dealer agrees to provide that signed copy to PCGS CURRENCY in the event of any actual or threatened claim against PCGS CURRENCY.
  10. Exclusive jurisdiction and venue for any dispute arising from the submission of items to PCGS CURRENCY shall be in the Superior Court, Orange County, California, and Customer agrees to waive any right to a trial by jury in any such action, and further agrees that the prevailing party in any such action shall be entitled to an award of its attorney's fees and costs.

I have read the PCGS CURRENCY Grading Terms and Procedures set forth above. I agree to abide by those terms and procedures, and further agree that PCGS CURRENCY is a third party beneficiary entitled to rely upon and benefit from my agreement to those terms and procedures. Customer: Sign above.

TO CHECK THE STATUS OF YOUR SUBMISSION, GO TO WWW.PCGSCURRENCY.COM OR CALL PCGS CURRENCY CUSTOMER SERVICE 1-800-447-8848
2008 Collectors Universe, Inc. Rev. 04/08