Form MA-930 Form MA-930 Maritime Administration Annual Service Obligation Report

OMB No. 2133-0509
Expiration Date 8/31/2015

Maritime Administration
Annual Service Obligation
Compliance Report

U.S. Department of
Transportation
Maritime
Administration

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 Information 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 their 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:

3. Date of Birth

2. Name (Last, First, Middle)

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

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

7. Are you Full Time Active Duty Military?

Yes

6. Calendar
Year Reporting

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:

Yes

Unit

No

Reserve Center

11 Have you Renewed or Upgraded your USCG License since last report?
Yes

No Date of Renewal/Upgrading (Month/Year)

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

/ Engineer

(Cell )

14. Date Issued

Yes

(Day)



(Evening)

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

License and credential Expiration Date:

17. Have you obtained the following? Common Access Card (CAC)
CAC Card

12.. Telephone:

No

CAC Reader

Yes

18. Have you obtained a Transportation Workers Identification Card (TWIC)?
No

Yes

No

Expiration Date: _________________

Yes

No

E Expiration Date: _________________

19. Valid Standards of Training, Certification and Watchkeeping (STCW95) endorsements since last report?

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 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

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

Exact Title of Your Position
Period Covered (Month/Day/Year)

Employment Type (Check Only One Box)
a.
b.
c.
d.
e.
f.
g.

Afloat (See*)
Maritime Related Ashore
Federal / State Government
Maritime Related
Non-Maritime
Graduate School
Unemployed
Active Duty Military / NOAA Corps

*Vessel (Name and Registry)
U.S.

MA-930 (08-12)

Foreign

OMB No. 2133-0509
Expiration Date 8/31/2015

B

Employer’s Name

Employment Type (Check Only One Box)

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

a.
b.
c.

Exact Title of Your Position

d.
e.
f.
g.

Afloat (See*)
Maritime Related Ashore
Federal / State Government
Maritime Related
Non-Maritime
Graduate School
Unemployed
Active Duty Military / NOAA Corps

*Vessel (Name and Registry)

Period Covered (Month/Day/Year)

U.S.

C

Employer’s Name

Foreign

Employment Type (Check Only One Box)
a.
b.
c.

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

d.
e.
f.
g.

Exact Title of Your Position

Afloat (See*)
Maritime Related Ashore
Federal / State Government
Maritime Related
Non-Maritime
Graduate School
Unemployed
Active Duty Military / NOAA Corps

*Vessel (Name and Registry)

Period Covered (Month/Day/Year)

U.S.

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)

Foreign

Date

PRIVACY ACT STATEMENT: 46 CFR 310 authorizes collection of this information. The principal purpose of this information is to determine compliance with Training
Agreements and Service Obligation Contracts and status in the US armed forces or Naval Reserve. Routine use is to monitor and update information in MARAD’s
Maritime Service Compliance System, monitoring system. 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-930 (08-12)