46 CFR Appendix Exhibit No. 1 to Subpart O of Part 502 - Reparation Statement To Be Filed Pursuant to Rule 252

Claim of ____________________ under the decision of the Federal Maritime Commission in Docket No. ____________________.

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)