( ),__________ (, , )
(type and name of ship)___________owned by (State, Ministry, Company or private firm)
1. (, , , , . .)
Geographical location of accident at sea and of the place where assistance has been (ocean, sea, latitude, port, etc.).
2. (, , ) ,
Time of accident (date, hour, minutes) by the disabled ship's Log Book.
3. (, , ).
Time of arrival of salvors (date, hour, minutes ).
4. , , (, , ).
Time when the disabled vessel consented to accept salvage assistance or when the Salvage Agreement has been signed (date, hour, minutes).
5. .
Time and place of termination of salvage operations.
6. , (, , , ).
Time of termination of towage of the disabled vessel, and place where to the wrecked vessel has been taken (bay, roads, port, berth).
7. , , .
Condition of the wrecked vessel as the beginning of salvage operation.
8. , :
Main data of the wrecked vessel:
| displacement | |
| length | |
| beam | |
| freeboard depth | |
| mean draft | |
| type and name | |
| Type and number of main engines, | |
| kind of fuel used |
9. , , .
Condition of the wrecked vessel at the time of termination of operation.
10.
Vessels which took part in the operation
11. ;
Technical means and appliances used
12.
Names of Divers who participated in salvaging
13.
Boatswains crews taking part in salvaging
14. ( , )
Materials and stores consumed (others then owned by the wrecked vessel)
15. ( , ):
Fuel and lubricants consumed (other than owned by the wrecked vessel):
16. ( ):
Description and quantity of cargo damaged and jettisoned during salvage operations:
17. Brief summary of work performed
18.
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|
|
Date and place of signing the Statement
,
Master of the Salvor Master of the Wrecked Vessel
| , . ( ) ...... ( ) . ( ) ( ) ... ( ) , , , , / /, : 1. . 2. . | Whereas the Ship or Vessel called the . whereof (name of the Ship or vessel) .. is Master, on a voyage (name of the Master) of the ..from (date of the voyage) to...... (port of the shipment) (port of destination), as is a Ileged by the Carrier sustained damage or loss and incurred expenditure which may be allowed as General Average, We, the Undersigned Consignees of Goods (or their Agents on their behalf) HEREBY UNDERTAKE in respect of the Goods as per Bi I Is of Lading enumerated hereunder: 1. to declare the value of Goods; 2. to pay General Average Contribution due according to the Average Statement. |
. 199_ r. City of .day of .199..
.. . Signature of Consignees.
. Legal Address of Consignees .
