FMC Form 33

FMC Form-33 (8/2019)

OMB Control No. 3072-0072

Federal Maritime Commission
Dispute Resolution Services Request -Cargo

Return to CADRS@fmc.gov, fax 202-275-0059, or CADRS, 800 N. Capitol St., NW, Washington, DC 20573

Person Requesting Assistance
Name:
Business Name:
VOCC

Type of business (check one):

NVOCC

))

MTO

Importer

Exporter

Customs Broker

Other

Current Address:
City:

State/Province:

ZIP/Postal Code:

Preferred Phone Number (9AM-5PM EST):

E-Mail:

Name of attorney (if any):

Attorney’s phone number:

Country:

Attorney’s email address (if any):

Dispute is With
Business Name:
Address:
Type of business (check one):

VOCC

NVOCC

MTO

))

Importer

Exporter

City:

State/Province:

ZIP/Postal Code:

Phone:

E-Mail:

Fax:

Customs Broker

Other

Country:

Have you contacted anyone at this company about your complaint?
If so, please indicate who:

What is the best way to contact:

Nature of Dispute
Type of Shipment (check one):

Household Goods

Commercial Cargo

Import to U.S.?
This dispute is related to (check one):

Export from U.S.?
Freight rate
Loss/damage

Demurrage/Detention/Per diem
Other

Non-Delivery

If other, please explain:
Date of transaction:
Amount in controversy: $
Desired solution:
How did you hear about FMC/CADRS?

P l e a s e e x p l a i n y o u r d i s p u t e a n d a t t a c h a l l r e l e v a n t d o c u m e n t s ( e .g .: B i l l s o f L a d i n g , S h i p p i n g
Contracts, B ook ing Confirm ations, Correspondence, etc… )

Affirmation: I understand that the information that I have provided is for the purpose of convening the use of
confidential ombuds or mediation services to resolve an ocean shipping dispute. As such, I authorize CADRS to contact
the named party(ies) to engage in efforts to seek resolution to this matter. Also, in the event that this matter falls
outside of FMC jurisdiction, I authorize CADRS to refer my request for assistance to the appropriate governmental
agency possessing jurisdiction over my complaint. Unless otherwise marked confidential in this intake form or
attached documents, I authorize CADRS to disclose information provided in the intake form to the other named
party(ies) for the purpose of exploring resolution to this dispute. I understand and agree that CADRS’s staff will act
as a neutral third party in my ombuds or mediation matter and as such CADRS cannot provide me with legal
representation or advice. I also understand and agree that ombuds services and mediation are voluntary processes
and that any party and/or CADRS may decline or terminate ombuds or mediation services at any time. I affirm that the
information provided in this intake form, to the best of my knowledge, is true and accurate.
Signature:

Date:

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply
with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid
OMB Control Number. The OMB Control Number for this information collection is 3072-0072. Public reporting for this collection of information is
estimated to be approximately 10 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and
reviewing the collection of information. All responses to this collection of information are voluntary, and will be provided confidentiality to the extent
allowed by the Freedom of Information Act (FOIA) and the Alternative Dispute Resolution Act (ADRA). Send comments regarding the burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal
Maritime Commission, 800 N. Capitol Street, NW, Washington, DC 20573