Ma-1023 Request For Administrative Waiver Of The Jones Act

Form Approved: OMB No. 2133-0529
Expiration Date: 01/31/2015
This collection of information is required to obtain a waiver of the U.S.-build and other requirements of the Passenger Services Act
(46 U.S.C. 55103) and will be used by the Maritime Administration to determine if the applicant is entitled to a waiver. Public
reporting burden is estimated to average one hour per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. No
assurances of confidentiality are provided. Please note that an agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this
collection is 2133-0529. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to: Information Collection Clearance Officer, Maritime Administration, 1200 New
Jersey Avenue, S.E., MAR-390, W26-494, Washington, D.C. 20590.

REQUEST FOR ADMINISTRATIVE WAIVER OF THE JONES ACT
46 U.S.C. 12121, 46 C.F.R. 388

1. Name of the Vessel:

2. Owner Information:
Name: ___________________________________

Telephone No: ________________________________

Address: _________________________________

Fax No: _____________________________________

_________________________________

Email: ______________________________________

3. Vessel Official Number (or Hull Identification No., or State No.):
4. Date of Vessel Construction:
5. Place of Construction:
6. Size, capacity and net tonnage of the vessel.
Size:

______________length

___________ net tonnage

Capacity: ______________ passengers
7. Intended commercial use of the vessel (attach pages if needed):

8. List all State(s) of intended operation and trade (“All States” is not acceptable):
9. A statement on the impact this waiver will have on other commercial passenger vessel operators, including a
statement describing the operations of existing operators (attach pages as needed):

10. A statement on the impact this waiver will have on U.S. shipyards (attach pages as needed):

11. By submitting this information you are deemed to have certified that the
above information is true and correct:

13. Email to
SmallVessels@dot.gov
or Mail to:

Small Vessel Waiver Program
12. Submit your $500.00 payment via:
Maritime Administration
https://www.pay.gov/paygov/forms/formInstance.html?agencyFormId=1071542 MAR-730, MS #2 W23-454
1200 New Jersey Ave., SE
website.
Washington, DC 20590
FORM MA-1023 (11-14)