Section 105IAC5-1-16. Monetary adjustments

   The claim for seeking monetary adjustments shall be substantially in the following form:

  Claim of __________ under decision of the public service commission of Indiana in Docket No. _________.

		Date of shipment
		Date of delivery or tender of delivery
		Date charges were paid
		Car initials
		Car number
		Origin
		Destination
		Route
		Commodity
		Weight
		Rate
		Amount
		Rate
		Amount
		Refund (or monies due) on basis of commission's decision
		Charges paid by (1)

  Claimant hereby certifies that this statement includes claims only on shipments covered by the findings in the docket above described and contains no claim for refund (or monies due) previously filed with the commission by or on behalf of claimant or, so far as claimant knows, by or on behalf of any person, in any other proceedings, except as follows: (here indicate any exceptions, and explanations thereof).

___________________________

(Claimant)

By:________________________

___________________________

(Address)

___________________________

(Date)

  Total amount of refund (or monies due) $_____. The undersigned hereby certifies that this statement has been checked against the records of this company and found correct.

  Date_____ concurred (2) in:_____ Company _____Company. Defendant Collecting Carrier, Defendant (3)_____.

  By_____, Auditor. By _____ Auditor.

(1) Here insert name of person paying charges in the first instance, and state whether as consignor, consignee, or in other capacity.

(2) For concurring certificate in case the collection carrier is not a defendant.

(3) If not a defendant, strike out the word "defendant". (Indiana Department of Transportation; 105 IAC 5-1-16; filed May 18, 1983, 2:18 p.m.: 6 IR 1209; readopted filed Nov 7, 2001, 3:20 p.m.: 25 IR 899; readopted filed Jun 14, 2007, 2:45 p.m.: 20070627-IR-105070237RFA; readopted filed Oct 2, 2013, 11:39 a.m.: 20131030-IR-105130295RFA) NOTE: Transferred from Department of Transportation (100 IAC 6-1-16) to Indiana Department of Transportation (105 IAC 5-1-16) by P.L.112-1989, SECTION 5, effective July 1, 1989.