(Marine Protest by Ship Captain)

Republic of the Philippines)
Province of ____________________) S.S.
City/Municipality of _____________)
x--------------x

MARINE PROTEST

Name: ______________ Age: _____Civil Status: _______

Address: _________________________________
Position: __________________Type/Cargo: ___________
Home Port: ___________________________________
Registry Number: ___________________________
Burden/Cargo: _____________________________
Gross Tons:_____________ Net Tons: ____________

After being duly sworn to in accordance with law, do hereby declared and
state on 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 I as Master (Indicate the respondents and their address if any.)

_________________________________.

That the prevailing weather at the time was as follows:

General Description: ______________________

Wind Direction: _______Velocity: ____ Kits: _________
Height of Seas: _________Feet: ____________
Tide: __________________ Flood ____________
Visibility: ___________________________
Other Remarks: _____________________
That the incident resulted injuries to ___________________ persons and
death to _____________ persons, whose names are listed in Exhibit
"A" of this PROTEST
That this incident likewise resulted to loss or slight damage to the
_____________ belonging to _____________ in the estimated
amount of ______________________________ (P____________) and
detailed in Exhibit "B" of this PROTEST:
That my organization / shipping company is as follows:

Company:___________________________
Address: __________________________
Telephone(s) _______________________
Fax: ______________________________

That further/additional information/data is appended hereto as Exhibit

"1" of this PROTEST.

SHIP CAPTAIN

(JURAT)