vessel reimbursement form

ASM
VESSEL REIMBURSEMENT FORM
TRIPS LONGER THAN 24 HOURS ONLY

TRIP ID # ____________
Subsistence Reimbursement Form for Vessel Master on F/V ___________________
for At-Sea Monitor (name) ____________________________
Date Sailed: ____________ Time Sailed: ____________
Date Landed: ___________ Time Landed: ___________
Total Hours at Sea: __________hrs
Total Reimbursement: __________
Reimbursement is for trips that are greater than 24 hours dock to dock. For each 24 hour
period starting when the vessel sails it will be reimbursed $40. The chart below defines the
reimbursement:
Total Time at Sea
0 to < 24 hours (< 1 day)
24 to 47.9 hours (1 day)
48 to 71.9 hours (2 days)
72 to 95.9 hours (3 days)
96 to 119.9 hours (4 days)
120 to 143.9 hours (5 days)
144 to 167.9 hours (6 days)

Vessel
Reimbursement
$0
$40
$80
$120
$160
$200
$240

Total Time at Sea
168 to 191.9 hours (7 days)
192 to 215.9 hours (8 days)
216 to 239.9 hours (9 days)
240 to 267.9 hours (10 days)
264 to 287.9 hours (11 days)
288 to 311.9 hours (12 days)
312 to 335.9 hours (13 days)

___________________________
Monitor’s Signature

____________
Date

___________________________
Captain’s Signature

____________
Date

Vessel
Reimbursement
$280
$320
$360
$400
$440
$480
$520

Please make check payable to __________________________________________
Attn:

______________________________________

F/V

______________________________________

Street

______________________________________

City, State, Zip ______________________________________
MAIL TO:

AIS, Inc.
P.O. Box 2093
New Bedford, MA 02741

Last updated April 2012