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5 U.S.C. 504, 551, 552, 553, 556(c), 559, 561-569, 571-584; 591-596; 18 U.S.C. 207; 28 U.S.C. 2112(a); 31 U.S.C. 9701; 46 U.S.C., 40103-40104, 40304, 40306, 40501-40503, 40701-40706, 41101-41109, 41301-41309, 44101-44106, 46105; 5 CFR part 2635.
49 FR 44369, Nov. 6, 1984, unless otherwise noted.
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| 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. | |||||||||||||||
| 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) |