(Operations manager, port captain, master, or other officer) of the vessel ____________ declare that I have knowledge of the facts set forth herein, and that upon the lading of the articles described below covered by withdrawal No. ________, filed at ________________(Name of port), the vessel then proceeded in ballast to ________________(Name of port) to lade cargo or passengers; that the vessel was suitable for service in the class of trade checked below with fittings, outfit, and equipment for such trade already installed when it so departed in ballast; and that upon arrival it proceeded to engage in the carriage of cargo or passengers in such trade, except as stated below:
_______________________________
(If no exception, note "None")
Description of articles:
_______________________________
_______________________________
_______________________________
_______________________________
(Name and title)
19 C.F.R. §10.64