FMC Form-33 Dispute Resolution Services Request - Cargo

FMC Form-33 OMB Control No. XXXX-XXXX

Federal Maritime Commission Dispute Resolution Services Request - Cargo
Person Requesting Assistance
Name:
Business Name:
Type of business (check one): __VOCC __NVOCC __FF ___MTO __ Importer ___ Exporter ___ Customsbroker __other
Current Address:
City:	State/Province:		ZIP/Postal Code:	Country:
Preferred Phone Number (9AM-5PM EST):			E-Mail:
Name of attorney (if any):			Attorney’s phone number:
Attorney’s email address (if any):
Dispute is With
Business Name:
Address:
Type of business (check one): __VOCC __NVOCC __FF ___MTO __ Importer ___ Exporter ___ Customsbroker __other
City:	State/Province:		ZIP/Postal Code:	Country:
Phone:	E-Mail:		Fax:
Have you contacted anyone at this company about your complaint?
If so, please indicate who:		What is the best way to contact:
Nature of Dispute
Type of Shipment (check one): _ Household Goods _ Commercial Cargo
Import to U.S.?		Export from U.S.?
This dispute is related to (check one): __ Freight rate __Demurrage/Detention/Per diem __ Non-Delivery ___ Loss/damage ___Other
If other, please explain:
Date of transaction:
Amount in controversy: $
Desired solution:
How did you hear about FMC/CADRS?
Please explain your dispute and attach all relevant documents (e.g.: Bills of Lading, Shipping Contracts, Booking Confirmations, Correspondence, etc…)
Affirmation: I understand that the information that I have provided is for the purpose of convening the use of confidential ombuds or mediation services to resolve an ocean shipping dispute. As such, I authorize CADRS to contact the named party(ies) to engage in efforts to seek resolution to this matter. Also, in the event that this matter falls outside of FMC jurisdiction, I authorize CADRS to refer my request for assistance to the appropriate governmental agency possessing jurisdiction over my complaint. Unless otherwise marked confidential in this intake form or attached documents, I authorize CADRS to disclose information provided in the intake form to the other named party(ies) for the purpose of exploring resolution to this dispute. I understand and agree that CADRS’s staff will act as a neutral third party in my ombuds or mediation matter and as such CADRS cannot provide me with legal representation or advice. I also understand and agree that ombuds services and mediation are voluntary processes and that any party and/or CADRS may decline or terminate ombuds or mediation services at any time. I affirm that the information provided in this intake form, to the best of my knowledge, is true and accurate.
Signature:					Date:

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is XXXX-XXXX. Public reporting for this collection of information is estimated to be approximately 10 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are voluntary, and will be provided confidentiality to the extent allowed by the Freedom of Information Act (FOIA) and the Alternative Dispute Resolution Act (ADRA). Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Maritime Commission, 800 N. Capitol Street, NW, Washington, DC 20573