Form MA-930 Maritime Administration Annual Service Obligation Compli

OMB No. 2133-0509

Expiration Date 9/30/2012

U.S. Department of Transportation Maritime Administration

Maritime Administration Annual Service Obligation Compliance Report

The information collected is required for MARAD to determine if respondent complied with terms of his/her maritime service obligation agreement during the reporting period. Public reporting burden of this collection of information is estimated to average one-half hour per response. Send comments regarding burden estimate or any other aspect of this information collection to the Maritime Administration, Office of Management and Administrative Services, 1200 New Jersey Ave., SE., Washington, DC 20590, and to the Office of Management and Budget, Paperwork Reduction project (2133-0509), Washington, DC 20503. Response to this collection is mandatory under 46 App. U.S.C. 1295b or 46 App. U.S.C. 1295c, as applicable. Confidentiality of information collected will be provided to the extent it is protected under the Privacy Act, 5 U.S.C. 552a. Note: 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 number is 2133-0509.

INSTRUCTIONS: This Compliance Report must be completed annually by all U.S. Merchant Marine Academy Graduates and State Maritime Academy Graduates in the Student Incentive Payment (SIP) Program for the period of your obligation after graduation. You are required to report to the Maritime Administration (MARAD) between January 1st and March 1st of each year. Graduates are encouraged to submit their Annual Compliance Report information to MARAD electronically, (https://mscs.marad.dot.gov). If submitting the information via the website is not possible the form can be submitted by mail to MARAD, Office of Maritime Workforce Development, MAR-740, 1200 New Jersey Ave, SE, Washington, DC 20590 or to [email protected] for SIP participants and to [email protected] for USMMA graduates. Retain a copy for your records.

PART I

1. U.S. Coast Guard Reference Number:

2. Name (Last, First, Middle)

3. Date of Birth - -

4. Address (Street, City, State, and Zip Code)

5. E-mail Address(es) Primary: Secondary Email:

6. Calendar Year Reporting

7 . Are you Full Time Active Duty Military? Yes No If yes, select your branch and period of the service and include current unit duty station in Part II - IV. Anticipated Separation Date:

8. Are you maintaining your Reserve Commission? Yes No Branch of Service

9. Maritime Academy Attended/Year Graduated: /

10. I have transferred to the Selected Reserve status and have affiliated with: Unit Reserve Center

11 Have you Renewed or Upgraded your USCG License since last report? Yes No Date of Renewal/Upgrading (Month/Year)

12.. Telephone: (Day) ( ) - (Cell ) ( ) - (Evening) ( ) -

13. U.S. Coast Guard License Serial No.

14. Date Issued

15. U.S. Coast Guard License(s) Held

16. Deck / Engineer License and credential Expiration Date:

17. Have you obtained the following? Common Access Card (CAC) CAC Card Yes No CAC Reader Yes No

18. Have you obtained a Transportation Workers Identification Card (TWIC)? Yes No Expiration Date: _________________

19. Valid Standards of Training, Certification and Watchkeeping (STCW95) endorsements since last report? Yes No E Expiration Date: _________________ PART II - EMPLOYMENT: An entry must be made for all periods of employment or unemployment during the Reporting Year. Begin with current status and work back covering the entire Report Year. Also, state how your position demonstrates employment in a maritime-related industry. Add additional information in Part III and attach additional sheets as needed. Unless you have received a deferral of your employment requirement, U.S. Merchant Marine Academy graduates must complete Part II to describe employment for the 5 year period after graduation and graduates of State Maritime Academies must complete Part II to describe employment for the 3 year period years after graduation. If you have filed annual reports on employment and that obligation is complete, indicate “fulfilled employment” in Part II when reporting on the remaining obligations i.e., USCG license and/or reserve status in Part I.

A

Employer’s Name

Employment Type (Check Only One Box) A float (See*) Maritime Related Ashore F ederal / State Government Maritime Related N on-Maritime G raduate School U nemployed A ctive Duty Military / NOAA Corps

Employer’s Address (Number, Street, City, State, Zipcode)

Exact Title of Your Position

Period Covered (Month/Day/Year)

*Vessel (Name and Registry) U.S. Foreign

B

Employer’s Name

Employment Type (Check Only One Box) A float (See*) Maritime Related Ashore F ederal / State Government Maritime Related N on-Maritime Graduate School U nemployed A ctive Duty Military / NOAA Corps

Employer’s Address (Number, Street, City, State, Zipcode)

Exact Title of Your Position

Period Covered (Month/Day/Year)

*Vessel (Name and Registry) U.S. Foreign

C

Employer’s Name

Employment Type (Check Only One Box) A float (See*) Maritime Related Ashore F ederal / State Government Maritime Related Non-Maritime Graduate School Unemployed Active Duty Military / NOAA Corps

Employer’s Address (Number, Street, City, State, Zip Code)

Exact Title of Your Position

Period Covered (Month/Day/Year)

*Vessel (Name and Registry) U.S. Foreign

PART III Describe how your position(s), duties, and responsibilities demonstrate how your employment is maritime-related.

PART IV Space for Additional Details. Indicate to which question this information applies.

CERTIFICATION I certify under penalty of perjury that all of the statements made by me are true, complete, and correct to the best of my knowledge and are made in good faith. A false answer to any question in this statement may be punishable by fine or imprisonment (18 U.S.C. 1001).

Signature (Sign in ink)

Date

PRIVACY ACT STATEMENT: 46 CFR 310 authorizes collection of this information. The principal purpose of this information is to determine compliance with Training and Service Obligation Agreements and status in the Naval Reserve. Routine use is to monitor and update information in MARAD (MSCS/SIPSAMS) monitoring system and Navy Management Information Systems. Completion of this form and furnishing your Social Security Number (which will be used by this agency only for the purposes indicated above) is voluntary; however, failure to provide this information represents non-compliance with Training and Service Obligation Agreements and could result in adverse administrative actions.

MA-903 (02-12)