Print Form

Authorized by

Initial Consumable Return Authorization Request Form

Samsung Electronics America
1. Please complete this RA form with detailed description of the problem.
2. Email this form back to Samsung along with Configuration Report (email: samsungb2bsupport9@sea.samsung.com)
3. Samsung will email back to you an RMA number within 72 Hrs or provide a reason for RMA denial.
4. After you receive an RA number, then you may return your defective consumable back to Samsung.
5. Please write the RA number on the outside of your shipping box
6. Ship the defective consumable back to Samsung within 15 days of receipt of the exchange consumable.
7. Incomplete form may delay the RA process.

Dealer Name Contact Person Purchase Place

A.B.S 32824442 Jerry Miceli Samsung
Address / City / State / Zip
16844 E AVENUE OF THE FOUNTAINS FOUNTAIN HILLS AZ 85268
Phone Number E-Mail Purchase Date
480-816-1222 JMICELI@ABSINC-SW.COM

RA #
Serial # of Printer Problem Description
Model Description Serial # of Cartridge (Internal
(15 Characters) (Include page count) Use)
Black Drum Black line in the middle of the page
CLX-8380ND 9861B1DQ600104R KRE1JC9603539BADUBQ8K0142 60739800
(CLX-R8380K) (12,000)
Black Drum Nosie and Shadow
SCX-6555 9D61B1DS500003V 14DMBGHB700855R
(R6555A) COPIES(40,852)

Note: Problem descriptions such as “defective” or “not working” are not acceptable.