Form MA-1023 Request for Administrative Waiver of the Jones Act

Form Approved: OMB No. 2133-0529

U.S. Department of Transportation
Maritime Administration

This collection of information is required to obtain a waiver of the U.S.-build and other requirements of the Passenger Services Act (46 App. U.S.C. 289) and will be used by
the Maritime Administration to determine if the applicant is entitled to a waiver. Public reporting burden is estimated to average one hour per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. No
assurances of confidentiality are provided. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. The OMB control number for this collection is 2133-0529.

REQUEST FOR ADMINISTRATIVE WAIVER OF THE JONES ACT
Public Law 105-383, Title V
1. Name of the Vessel:
2. Owner Information:
Name: _________________________________________________
Address: _________________________________________________
_________________________________________________
_________________________________________________

Telephone No.: ________________________
FAX No.: _________________________
Email: _______________________________

3. Vessel Official Number (or Hull Identification No., or State No.):
4. Date of Vessel Construction:
5. Place of Construction:
6. Size, capacity and tonnage of the vessel (state whether tonnage is measured pursuant to 46 U.S.C. 14502, or otherwise, and if
otherwise, how measured)
Size:
_______________ length
Capacity: ______________ passengers
Measured pursuant to 46 U.S.C. 14502?

_____________ tonnage (five (5) net ton minimum)
Yes

No

Other:_________________________________

7. Intended commercial use of the vessel (attach pages if needed):

8. Geographic region of intended operation and trade:

9. A statement on the impact this waiver will have on other commercial passenger vessel operators, including a statement
describing the operations of existing operators (attach pages as needed):

10. A statement on the impact this waiver will have on U.S. shipyards (attach pages as needed):

11. By submitting this information you are deemed to have certified that the above
information is true and correct:
12. Submit your $500.00 payment via
https://www.pay.gov/paygov/forms/formInstance.html?agencyFormId=1071542 web site
FORM MA-1023 (12-05)

13. Email to:[email protected]
Or Mail to:
Small Vessel Waiver Program
Maritime Administration
MAR- 830, Room 7201
400 Seventh St., SW
Washington, DC 20590