FMC Form 32 - Dispute Services Request - Cruise

FMC Form-32 [DATE]

Federal Maritime Commission
Dispute Services Request – Cruise

OMB Clearance No. 3072-0072

Return to [email protected], fax (202) 275-0059, or FMC CADRS, 800 N. Capitol St., NW, Washington, DC 20573

Person Requesting Assistance:
Name:
Current address:
City:

ZIP Code:

State:

Country:

Ticket or Booking Number:
Preferred phone number (9AM-5PM EST):

E-Mail:

Attorney’s name (if any):

Attorney’s phone number:

Attorney’s email:

Dispute is with:
Name:
Address:
City:

State:

ZIP Code:

Phone:

E-Mail:

Fax:

Travel Agent Name:

Country:

Travel Agent Phone Number:

Travel Agent Mailing Address:

Nature of Dispute :
Does your dispute involve:
Casualty
Non-performance
Other
Did the cruise begin at a U.S. port?
How did you hear about the FMC/CADRS?

Yes

No

**Desired resolution:

**You are requesting FMC/ CADRS assistance in resolving your dispute. For more information see w w w .fm c.g o v / databases-services/
alternative-dispute-resolution-services.

Please explain the dispute as fully as possible: Have you filed a complaint with the cruise line? Have you
contacted anyone else for assistance? Did you purchase any travel insurance? How did you book your cruise
(e.g., online, travel agent, other). Attach all relevant documents.

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 a cruise related 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 staff will act as a neutral third party in my ombuds or mediation matter and as such CADRS’s
staff cannot provide me with legal representation or advice. I also understand and agree that ombuds services and mediation
are voluntary and that any party and/or CADRS staff 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 3072-0072. 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.