MA-828 Vessel Data

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u.s. Dlpartment

d Tror"8POrtolton

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VESSEL DATA
(For use in determining war risk insurance valuation)

The following information is to be submitted in duplicate to the Maritime Administration in connection with (a) 0 the application
for, or (b) 0 the binder already issued for, war risk hull insurance on the below named vessel and may be relied on by the
Administration in determining the value of the vessel for.total or constructive total loss purposes pursuant to 46 CFR Part 309
and any amendments thereof published in the Federal Register prior to the date this form is filed with the Maritime Administration.
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1. Name of vessel

2.-Official

3. Name of owner

4. Address of owner

5. Rag of registry

6. Classification society

7. Prior name or namesof vessel,if any

8. Type

9. Total deadweight tonnage
12. Speed

No

10. Gross tonnage

11. Nettonnage

13. Horsepower

14. Type of propulsion

15. Constructioncost

16. Date purd1asedby owner

17. Purchase price paid by owner
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188. Describeany specialequipmentcoming under46 CFR Part 3O9.6(b).Give dates of installation,itemizedactualcosts,and
state by whom work was done.

No War Risk Hull InterimBinderwill be issued, renewed,or extendedunlessthis form has been completed(46 U.S.C.1269;
46 CFR S~io~ ~8~3 a~d 309.8). -Form MA-828
(Rev. 4-96)

18b. If rebuiltor if capital improvements,excludingspecialequipmentlisted in paragraph(188.)were made, give dates;
itemizedactual costs. and state by whomwork was done.

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19. The vesselwas 0 built, 0 reconstructed.0 reconditionedwith the aid of constructionsubsidyunderTitle V of the
MerchantMarineAct. 1936,as amended,or 0 is otherwisesubjed to the provisionsof Section802 of said Act.

Contractdated

Contract No

208. If any part of the costs of the i~ements
listed in paragraph18 was borne directly or Indirectlyby the UnitedStates,
state the nature of the improvements. and the portionof the costs borne by the UnitedStates.(See 46 CFR Part 3O9.6(c»

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2Ob.If the costs of any of the improvementslisted in paragraph18 were estimatedat the time the vessel was purchased.and
if any allowancewas made in the purchaseprice for any of them. state the amountsof the allowancesand for what they
were made.

-21. Give the schedule of depreciation adopted
--~for the vessel by the Internal
Revenue
-Service for income tax purposes

22. G~e t~ net ~ value -of the vessel at the CioN ofihe latMt ~x year. and-show in~taH how ~s
includingrate of appreciationapplied.

Form MA-828
(Rev.4-N)

determined;

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24. If the vessel is in substandardconditionfor a vesselof her type and age, state W1
what respect,otherwiseit will be
assumedthat the owner warrantsthat the vessel is up to the recognizedstandardsfor a vesselof her type and age as
specifiedabove,exceptingonly ordinarywear and tear whichwouldoccur in normalcommercialtrading notwithstanding
good commercialmaintenancepractices.

The foregoinginformationis true to tte best of my knowledge,Information.and belief
Name of owner

By (Authorized signature)

TITlE

DATE

NOTE: The UnitedStatesCriminalCode makesit a criminaloffensefor any personknowinglyto make a false statementor
representationto, or to conceala materialfact from,any departmentor agencyof the UnitedStatesas to any matterwithin its
jurisdiction(18 U.S.C. 1001),or to file a false,fictitiousor fraudulentclaim againstthe UnitedStates(18 U.S.C.287).
Form MA-828
(Rev.4-H)