105 Ind. Admin. Code 5-1-37
Authority: IC 8-1-1-3
Affected: IC 8-3-1-3; IC 8-3-1-8
Sec. 37.
Claims for reparations shall be substantially in the following form:
Claims of __________ under decision of the public service commission of Indiana in Docket No. _____ .
_____ Date of shipment
_____ Date of delivery or tender of delivery
_____ Date charges were paid
_____ Car initials
_____ Car number
_____ Origin
_____ Destination
_____ Route
_____ Commodity
_____ Weight
_____ Rate
_____ Amount
_____ Rate
_____ Amount
_____ Reparation on basis of commission's decision
_____ Charges paid by (1)
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 commission 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 explanations thereof).
______________________________
(Claimant)
By: ___________________________
______________________________
(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 (2) in: _____ Company _____ Company. Defendant Collecting Carrier, Defendant (3) _____ .
By _____ , Auditor. By _____ Auditor.
105 IAC 5-1-37
Transferred from Department of Transportation ( 100 IAC 6-1-37) to Indiana Department of Transportation ( 105 IAC 5-1-37) by P.L. 112-1989, SECTION 5, effective July 1, 1989.