REPUBLIC OF THE PHILIPPINES)

City/Municipality )
Port of )

MARINE PROTEST

Name: ______________________________ Age: ____ Civil Status: _________

Address:_________________________________________________________

Master of: ____________________ Type/Class__________________________

(Vessel)

Home Port:_______________________________________________________

Registry Number: __________________________________________________

Burden/Cargo: ____________________________________________________

Gross Tons: _______________________ Net Tons: ______________________

After being duly sworn to in accordance with law, do hereby declared and state
of protest:

That on (Continue with facts and 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

SUBSCRIBED AND SWORN to before me PROTESTANT exhibiting to me his

Seaman’s Identification and Record Book No._____________________ issue at
___________________ on_____________ or Residence Certificate No.___________of
(country)________________ issued at _______________ on
____________________.

_____________________
(Notary Public)