Claim of __ under decision of the Surface Transportation Board in Docket No. ___.
__ Date of shipment.
__ Date of delivery or tender of delivery.
__ Date charges were paid.
__ Car (or vessel) initials.
__ Car (or voyage) number.
__ Origin.
__ Destination.
__ Route.
__ Commodity.
__ Weight.
__ Rate.
__ Amount.
__ Rate.
__ Amount.
__ Reparation on basis of Board's decision.
__ Charges paid by.
Claimant hereby certifies that this statement includes claims only on shipments covered by the findings in the docket above described and contains no claim for reparation previously filed with the Board by or on behalf of claimant or, so far as claimant knows, by or on behalf of any person, in any other proceedings, except as follows: (Here indicate any exceptions, and explanation thereof).
_______________________________
(Claimant)
By _______________________________
(Practitioner)
_______________________________
(Address)
_______________________________
(Date)
Total amount of reparation $___. The undersigned hereby certifies that this statement has been checked against the records of this company and found correct.
Date ___ Concurred in: ___ Company ___ Company, Defendant Collecting Carrier, Defendant . ___
By ___, Auditor. By ___, Auditor.
49 C.F.R. §1133.2