Marine Protest Format

 Annex: A – PCG Form 8- (11/90) (11/90) REPUBLIC OF THE PHILIPPINES) City/Municipality Port of

: ) MARINE PROTEST

Name: ________________________________Age: ________________________________Age: ____ Civil Status__________   Address:___________________________________  Address:_________________________________________________________  ______________________  Master of: ______________________Typ ______________________Type/Class_____________ e/Class__________________________  _____________  (Vessel) Home Port:_______________ Port:_________________________________________ ________________________________________  ______________  Registry Number: ________________________ __________________________________________________  __________________________  Burden/Cargo: ___________________________ ____________________________________________________  _________________________  Gross Tons: _______________________ Net Tons: ______________________   After being duly duly sworn to in accordance accordance with law, law, do hereby declared declared and state of protest: That on (Continue with facts and circumstances circumstances that transpired in the incident)  _____________________________________________________  _________________________ ______________________________________________________ ______________________________________________________ ____________________________________  ________   ______________________________________________________________________________  __________________________________________________ ________________________________________________________ ___________________________________________  _______________   _________________________.  ________________________ _. That I as Master, (Indicate what actions the master initiated)  _____________________________________________________  _________________________ ______________________________________________________ ______________________________________________________ ____________________________________  ________   ______________________________________________________________________________  __________________________________________________ _____________________________________________  _________________  That I as Master, (Indicate the respondents and their address if any)  _____________________________________________________  _________________________ ______________________________________________________ ______________________________________________________ ____________________________________  ________   ________  That the prevailing weather at that time is described as follows: General Description: ____________________________________________  ____________________________________________  Wind Direction: ________________ Velocity: ________ Knots: ___________  Height of Seas: ___________ Feet: Tide:

Ebb

Flood

Visibility: _________________________ _____________________________________________________ ________________________________  ____  Other Remarks: That this incident resulted in injuries to ______________________________________ persons and death to _______________ persons, whose name are listed in Exhibit “A” of this Protest: That in this incident likewise results in loss of or damage to property estimated at _______________________ Pesos (P__________) and detailed in Exhibit “B” of this PROTEST: That my organization/shipping company is as follows: Shipping Line/Company: _______________________________________   Address: ________________________________ ___________________________________________________  ___________________  Telephone(s) _________________________ ________________________________________________  _______________________  FAX: ________________________ ____________________________________________________ ______________________________  __  That furthers/additional supporting information/data are appended hereto Exhibit “C” of this PROTEST:

 _____________________  Master  SUBS SUBSCR CRIB IBED ED AND AND SWOR SWORN N to befo before re me PROT PROTES ESTA TANT NT exhi exhibi biti ting ng to me his his No._ No.___ ____ ____ ____ ____ ____ ____ ____ ____ ____ __ issu issue e at ____ ______ ____ ____ ____ ____ ____ ____ ___ _ on__ on____ ____ ____ ____ ____ ___ _ or (country)________________ (country)________________ issued at _______________ on  ____________________.

 _____________________  (Notary Public) Commission Expires: ____ 

Seam Seaman an’s ’s Ident Identif ific icat atio ion n and and Reco Record rd Book Book Resi Reside denc nce e Cert Certif ific icat ate e No._ No.___ ____ ____ ____ ____ __of  of