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MAIL-IN REBATE
Authorized Agent/Retailer Customers
When you buy and activate the following equipment, please check the box of the device you purchased.
• Two year contract required.
Offers valid 10/15/14 through 10/31/14
Must be postmarked within 30 days of purchase date
PROOF OF PURCHASE (UPC)
REBATE AMOUNT
∫ Samsung Galaxy S® 4 - Black Mist
8-87276-98457-5
8-87276-95647-3
$100
∫ Samsung Galaxy S® 4 - Black Mist 32GB
8-87276-85360-4
8-87276-68975-3
$100
∫ Samsung Galaxy S® 4 - Brown Autumn
8-87276-85075-7
8-87276-95648-0
$100
∫ Samsung Galaxy S® 4 - White Frost
8-87276-98825-2
8-87276-95649-7
$100
∫ Samsung Galaxy S® 4 - White Frost 32GB
8-87276-85352-9
8-87276-95642-8
$100
WIRELESS EQUIPMENT
SAMSUNG
Rebate questions? verizonwireless.com/rebates
See reverse for rebate submission instructions. Available at participating Authorized Agent/Retailers only. Rebates will
be mailed within 3 weeks after receipt of claim, but may take up to 6 weeks.
New 2-year activation required. Certain restrictions apply. Limit one rebate offer per wireless phone number and IMEI. Equipment must be activated on Verizon Wireless service to receive rebate.
Asurion insurance replacement devices are not eligible for rebate. Cannot be combined with other offers.
©2014 Verizon Wireless. All rights reserved.
REBINDS4101514
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To receive your rebate by mail, please complete this rebate form and submit the following:
1
CUSTOMER CONTACT INFORMATION (Use CAPITAL LETTERS)
Last Name
First Name
Billing Address
City
State
Zip Code
Wireless area code and phone number on rebate-eligible equipment (must be included).
(See Customer Agreement for Wireless No. or Eligible Wireless No.)
Email address:
(for rebate submission status only)
2
SALES RECEIPT
3
CUSTOMER AGREEMENT OR VERIZON WIRELESS SMALL BUSINESS RECEIPT
Copy of itemized sales receipt clearly indicating:
•Store name
•Date of sale
•Device purchased (make and model)
Copy of legible Customer Agreement (signed contract), dated between 10/15/14 through 10/31/14.
PLEASE ENSURE THAT ALL INFORMATION ON PHOTOCOPY IS LEGIBLE.
The following is required for agreements with multiple wireless numbers:
• First page with purchase location, Application ID (Appl. ID No.) and customer information
• Corresponding page indicating rebate-eligible wireless number and IMEI
4
ORIGINAL BARCODE LABELS (Photocopies will not be accepted)
• Include the entire original white barcode label cut from the outside of the device box.
• The barcode label includes two barcodes. One is the IMEI barcode and the other is the Proof of Purchase
(UPC) barcode.
Proof of Purchase (UPC) and IMEI label may be required for a full equipment refund. Return policies may vary at Verizon Wireless authorized retailers.
SIGN AND MAKE A COPY
This form must be signed, dated and postmarked within 30 days of purchase date.
Make a photocopy of all submitted materials for your records, including all barcode labels.
Signature
Date
MM
DD
YY
I certify by my signature that the information I have entered on this mail-in rebate form is accurate and complete. I agree to the terms and conditions as outlined on this form.
Rebate Form
Sales Receipt
+
Customer Agreement
PL
E
+
SA
M
SA
M
+
PL
E
DO YOU HAVE EVERYTHING?
Proof of Purchase (UPC) Barcode
Note: 2 weeks after you mail the rebate claim form, please visit our rebate center at verizonwireless.com/rebates to check the status of your rebate submission.
At our rebate center you can also obtain answers to frequently asked questions or register your rebate online. For general questions you can also call 1.800.457.0864.
MAIL TO:
Mail-In Rebate Offer
Promotion Code 14-529
P.O. Box 540047
El Paso, TX 88554-0047
Your rebate will be paid with a Visa® Prepaid Card. After activation, the card can
be used everywhere Visa® debit cards are accepted.
Cards are issued by Citibank, N.A. pursuant to a license from Visa U.S.A.
Inc. and managed by Citi Prepaid Services. Cards will not have cash access
and can be used everywhere Visa debit cards are accepted.
(One rebate request per envelope.)
Any mail-in rebate form or rebate card lost or misdirected by the US Postal Service or other delivery service is not the responsibility of Verizon Wireless or the Fulﬁllment Center. Overnight or certiﬁed mail may increase
processing time. Incorrect information, illegible or incomplete rebate forms will be considered invalid and ineligible for rebate and presumed to be customers’ acts or omissions. Verizon Wireless reserves the right to review
and approve all offers and modify or withdraw this promotion at any time for any reason. Rebate cards will be issued in US dollars only. Rebate cards are valid through the expiration date shown on the card. This rebate form
has no cash value. Reproduction, purchase, sale or trade of this rebate form or barcode label from equipment box is prohibited. Materials received become property of Verizon Wireless and cannot be returned. Offer valid
only in the United States for customers only. Fraudulent submissions could result in prosecution under US Mail Fraud Statute (18 USC Sections 1341–1342).
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