46 CFR Exhibit No. 1 to Subpart O [§502.252] of Part 502
2
April 15, 2021
Claim of __________ under the decision of the Federal Maritime Commission in Docket No. __________.
Open Table
| Date of B/L | Date of delivery or tender of delivery | Date charges paid | Vessel | Voyage No. | Port of origin | Destination port | Route | Commodity | Weight or measurement | As charged | Should be | Reparation | Charges paid by* | ||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Rate | Amount | Rate | Amount | ||||||||||||
*Here insert name of person paying charges in the first instance, and state whether as consignor, consignee, or in what other capacity.
Open Table
| Total amount of reparation $____________________. | |
| The undersigned hereby certifies that this statement has been checked against the records of this company and found correct. | |
| Date ____________________. | |
| ____________________ Steamship Company, Collecting Carrier Respondent, | |
| By ____________________, Auditor | |
| By ____________________, Claimant | |
| ____________________, Attorney | |
| (address and date) |
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