State of
County of

I, ___, (Name) being duly sworn, depose and say:

1. That I am the ___ (Title) of ___. (Name of party)

2. That I am fully acquainted with and have knowledge of the operations of all qualified agreement vessels owned or operated by my company and identified in Capital Construction Fund Agreement, MA/CCF ___.

3. That I have full knowledge of the trading restrictions and liquidated damages provisions pertaining to qualified agreement vessels, as stipulated in46 U.S.C. 53501 et seq, and in the rules and regulations of 46 CFR Part 390.

4. That based on my inspection of Company records and to the best of my knowledge and belief, except as noted below in statement 5 of this affidavit, during the period _____ (Beginning of taxable year) through _____ (End of taxable year) my company operated its qualified agreement vessels only in the United States, foreign, Great Lakes, and noncontiguous domestic trade in accordance with Capital Construction Fund Agreement, MA/CCF ___.

5. Exceptions to statement 4 of this Affidavit are as follows (indicate exceptions below or attach a supplemental statement if additional space is needed; if there are no exceptions, write “none”):


Subscribed and sworn to before me, a Notary Public in and for the State, City and County above named, this ______ day of ________, 19__.

(Notary Public)

My commission expires ____________, 19__

[41 FR 39751, Sept. 16, 1976; 74 FR 17097, Apr. 14, 2009]

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