Form MA-828 Vessel Data

OMB No. 2133-0011
Expiration Date: 09/30/2020
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 2133-0011. Public reporting for this collection of information is estimated to be approximately 95
minutes per response, including the time for reviewing instructions, completing and reviewing the collection of information. All responses to this collection of
information are voluntary. 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, MAR-390, 1200 New Jersey Avenue, SE, Washington, DC 20590.

U.S. Department of Transportation
Maritime Administration

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

The following information to be submitted in duplicate to the Maritime Administration in connection with (a)
the
application for, or (b)
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.
1. Name of Vessel

2. Official No.

3. Name of Owner

4. Address of Owner

5. Flag of Registry

6. Classification Society

7. Prior Name or Name of Vessel, if any

8. Type

9. Total Deadweight Tonnage

10. Gross Tonnage

11. Net Tonnage

12. Speed

13. Horsepower

14. Type of Propulsion

15. Construction Cost

16. Date Purchase by Owner

17. Purchase Price Paid by Owner

18a. Describe any special equipment coming under 46 CFR Part 309.6(b). Gives dates of installation, itemized actual cost,
and state by whom work was done.

No War Risk Hull Binder will be issued, reviewed, or extended unless this form has been completed 46 U.S.C. 1289; 46 CFR
Sections 308.3 and 309.8).
Form MA-828
(Rev. 7-2011)

18b. If rebuilt or if capital improvements, excluding special equipment listed in paragraph (18a.) were made, give dates:
itemized actual cost and state by whom work was done.

19. The vessels was built, reconstructed, reconditioned with the aid of construction subsidy under Title V of the
Merchant Marine Act, 1936, as amended, or is otherwise subject to the provisions of Section 802 of said Act.

Contract Dated

Contract No.

20a. If any part of the costs of the improvements listed in paragraph 18 was borne directly or indirectly by the United States,
state the nature of the improvements, and the portion of the costs borne by the United States. (See 46 CFR Part 309.6(c))

20b. If the costs of any of the improvements listed in paragraph 18 were estimated at the time the vessel was purchased, and
if any allowance was made in the purchase price for any of them, state the amounts of the allowances and 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. Give the net book value of the vessel at the close of the latest tax year, and show in detail how it was determined,
including rate of appreciation applied.

Form MA-828
(Rev. 7-2011)

23. If the vessel is not in class, state the amount estimated to place her in class, and give the basis for such estimate,
otherwise it will be assumed that the owner warrants that the vessel is in class. (See 46 CFR Part 309.6(a).)

24. If the vessel is in substandard condition for a vessel of her type and age, state in what respect, otherwise it will be
assumed that the owner warrants that the vessel is up to the recognized standards for a vessel of her type and age as
specified above, excepting only ordinary wear and tear which would occur in normal commercial trading notwithstanding
good commercial maintenance practices.

The foregoing information is true to the best of my knowledge, information, and belief.
Name of Owner

By (Authorized signature)

TITLE: ________________________________________________________________

DATE: __________________________

NOTE: The United States Criminal Code makes it a criminal offense for any person knowingly to make a false statement or
representation to, or to conceal a material fact from, any department of agency of the United States as to any matter within its
jurisdiction (18 U.S.C. 1001), or to file a false, fictitious or fraudulent claim against the United states (18 U.S.C. 287).

Form MA-828
(Rev. 7-2011)