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Submission form

You must include one submission form with each box or envelope you send to Box Tops. There is no limit to the number of Box Tops coupon bundles, Super Box Top bundles or Bonus certificates you include in each box or envelope. If you are sending multiple boxes or envelopes, each must include a completed submission form for the contents of that box or envelope. Send completed submission packages to: Send via U.S. Postal Service to: General Mills Box Tops for Education P.O. Box 2185 Young America, MN 55553-2185 Send via UPS, FedEx or other carriers to: General Mills Box Tops for Education 717 Faxon Road (Dept. 2185) Young America, MN 55397-9481 By signing, I certify that I am the authorized Box Tops for Education Coordinator for my organization. I understand that giving false information to the Box Tops for Education Program may be considered fraudulent under U.S. Mail Fraud Statutes (18 U.S.C. 1341 and 1342).

Print Name

Signature

Date

SUBMISSION INFORMATION

Box Tops School ID School Name School Address City Coordinator Name Principal Name State Zip Submission Date

Please include this entire submission form page with your box or envelope.

DETERMINE VALUE

Number of Box Tops Number of Bonus Box Tops Number of Super Box Tops

x 10¢ = x 10¢ = x 30¢ =

$ $ $ $

Total

Information

standardsubmissionform

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