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Dear American Airlines Customer,

Please accept our sincere apology for the mishandling of your property. We understand your concern and realize the inconvenience this
causes. Completion of this form in reference to a delayed bag will allow us to intensify our tracing efforts with the goal of locating and
returning your property.

Complete all areas of this form and return it to us no later than 45 days from the date of travel. Failure to return this completed form to us
within the timeframe may result in the denial of your claim.

If your claim involves more than one piece of baggage, please itemize each bag and its contents separately. Failure to include the
requested information may affect the processing of your claim.

Check list:
Airline ticket receipts
Baggage claim checks
Original receipts are required for all reimbursement for delay expenses
Receipt(s) for excess value claimed
Receipt(s) for excess baggage charges paid
Receipt(s) for all items valued over $150.00
Clear and legible government issued photo identification for each passenger making a claim
Damage claims: retain all damaged bags and/or contents until your claim has been resolved
Retain a copy of all documents submitted to the airline for your personal records

Once you have completed the form, please return it to us by mail or fax:

American Airlines, Inc.


Central Baggage
4000 E Sky Harbor Blvd.
Phoenix, AZ 85034
Fax 480-693-2305
Email: central.baggage@aa.com

Liability Limitations:
Liability for loss, delay, or damage to baggage will be limited as follows:
Domestic Travel (wholly within the United States) - $3,500 per ticketed passenger.
Certain items are excluded from liability; see Contract of Carriage at aa.com
International Travel (including domestic portions of international itineraries) is covered by the Montreal Convention 1,131 SDRs
(Special Drawing Rights) per ticketed passenger

Thank you for your cooperation,

Your American Airlines Central Baggage Team

OP124 (Rev 08/25/2015)


PASSENGER PROPERTY QUESTIONNAIRE
AAdvantage: ________________
03EW0N4 File Reference Number: ________________
CLLAA01925632

Type of Claim: (check all that apply)


Lost Luggage Missing Contents
Damaged Luggage and/or Contents Delay Expenses

Mr. First Middle Last Name Phone Number


Mrs.
Ms. MD SHUJAN ALI Home: Business:
7753575882 7753575882
Permanent Mailing Number Street Apt. Temporary Mailing Number Street Apt.
Address Address 510 1st Street, Apartment 2
City State City State College Station Texas
Zip Code Zip Code 77840

Country Country USA


Postal Code Postal Code

Email Address: Employed by: Texas A&M University


md.shujan.ali@gmail.com Occupation: Graduate Student

Your Complete Flight Itinerary


From To Airline Flight Number Travel Date

RENO, NV DALLAS FT WORTH, TX American Airlines AA1218 30 MAY 2017


DALLAS FT WORTH, TX COLLEGE STATION, TX American Airlines AA2866 31 MAY 2017

Have you, or any member of your household, had a previous baggage claim with AA or any other airline in the last 5 years? Yes No
If yes, list each airline, claimant name and dates (attach an additional page if necessary)
Airline(s) _________________________________________________________ Name(s) __________________________________________________________
Date(s) _____________________________________________________________________________________________________________________________
Information gathered on this form may be shared with other airlines, local, state and federal law enforcement agencies or private insurers.

Number of ticketed passengers Number of passengers Purpose of trip? Length of stay?


traveling in your party: 1 claiming missing baggage: 1 Attending University education 4 years
Were you charged for excess Yes No Did you declare and pay for excess value: Yes No
and/or overweight baggage: Value declared: $
Have you received your baggage and are you missing contents only: Yes No If yes, how many bags are missing contents?
Was airline notified of loss immediately? Yes No If yes, at what office? College Station, TX By telephone In person
If airline was not notified within 4 hours, state the reason for the delay:
Where and when did you last see your baggage? Reno Airport, NV
Has this loss been reported to another airline? Yes No If yes, please provide name of airline and city where reported.

Certification and Understanding


APPLICABLE IN USA ONLY. It is expressly understood and agreed by the claimant that the furnishing of this form and any assistance given by employees of
American Airlines, Inc., are acts of courtesy and shall not constitute a waiver of any rights or an admission of liability by or on the part of American Airlines, Inc., its
employees or agents. Any other information and/or documents relating to this statement which are required by American Airlines, Inc., will be furnished by claimant
upon request and shall be considered part of this statement.

The United States Post Office has investigative jurisdiction under federal laws relating to sending false or fraudulent claims through the United States mail and any
such claims received by American Airlines, Inc., are reported to the United States Postal Authorities. Loss of baggage in interstate shipment or of articles from such
baggage come within the purview of federal statutes relating to thefts from interstate shipment and, are therefore, subject to investigation by the Federal Bureau of
Investigation.
OP124
(Rev 08/25/2015) Complete Reverse Side
BAGGAGE AND CONTENT DESCRIPTION
NOTE: When more than one piece of baggage is lost, complete a separate baggage and content list for each missing bag.
Baggage routing: Flight number(s) on claim check: Airport checked from: Airport checked to:
4001073604 AA1218 RENO, NV DALLAS FT WORTH, TX
Baggage tag number(s): AA073604 Passenger ticket number(s): 0012125417974 (Record Locator PVIUVF)

Number of bags checked: 2 Number of bags received: 1 Baggage checked at: Curbside Ticket Counter Gate Other

Was baggage rechecked and new tags issued? Yes No If yes, at what airport? Reno, NV

Was baggage available at Customs? Yes No N/A If yes, at what city?


Give details if the original routing was changed after starting your trip:

Was your property packed in a box? Yes No Was your property packed with an external cover? (example: golf bag) Yes No

Is the name on the bag(s) different from the passenger? If so, what name? No
Please list any initials, marks, tags, ribbons, cords, tape or other exterior markings on your bag(s):
A silver colored Lock in the chain of bag

Bag Open/Close Retractable Purchase


Bag Type Material Color(s) Brand Wheels Cost of Bag
Dimensions with Zipper Handle Date

Sports Duffle Hard Purple Bego 11x15x27 inch Yes Yes Yes Jan-2017 $27.99
Bag Soft No No No

Gender = M: Male F: Female CH: Child I: Infant (under 2 yrs)


Qty Article/Item Size Gender Description Color Material Brand Label Store Purchase Original
M,F,CH,I Purchased Date Cost
1 Shoes 12 M White with blue stripes Leather Nike Sears Jan-13 $55.00
4 T-Shirts L M Undershirts White Cotton Hanes JCP Jan-13 $20.00
1 Color Image Scanner M N/A Image scanner Black Plastic Canon Amazon Sep-15 $58.46

6 Medicines N/A M Medicines N/A Unknown Many CollegePharmacy May-17 $140.00

1 Shoe 9 M Shoe Black Unknown N/A Wallmart Dec-16 $20.00

1 Winter Jacket L M Jacket BLU Unknown Old Navy Old Navy Jan-16 $60.00

4 Sweaters L M Sweater Different colors Cotton Old Navy Old Navy Jan-16 $100.00

3 Trousers M M Trousers Blue, Black Cotton & Polyester Walmart Jan-16 $60.00

3 Pants M M Pants Brown, Black Cotton & Polyeste JCPenny JCPenny Jan-16 $90.00

2 Shirts M M Shirts Red Strips Cotton & Polyester JCPenny JCPenny Jan-16 $100.00

2 Shirts M M Shirts White, Red Strips Cotton Old Navy Old Navy Jan-16 $50.00

1 Computer Keyboard M M Computer Keyboard & Mouse Black N/A Logitech Amazon May-16 $25.00
1 Body Weight Scale M M Weight Scale Black Glass Etekcity Amazon Jul-16 $18.88

If additional space is needed, please attach a separate page. Be sure to include a complete
description and cost for each item along with receipts for all items valued over $150.00. TOTAL: $ 722.34

I do hereby warrant the foregoing statement and those on the accompanying forms to be accurate, complete and true. I hereby
make a claim against American Airlines, Inc., in the amount of $___________________
750.33 for a loss occurring on__________________
May 31 .

____________________________________________________________
06/11/2017 ___________________________________________________________
06/11/2017
Claimant signature Date Claimant signature* Date
*Signatures are required for each passenger claiming lost property. Parents may sign for their children under age 18.

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