Section 105IAC5-1-37. Reparation statement

   Claims for reparations shall be substantially in the following form:

  Claims 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

_____  Reparation 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 reparation 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 reparation $_____. 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 5-1-37; filed May 18, 1983, 2:18 p.m.: 6 IR 1214; 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 6-1-37) to Indiana Department of Transportation (105 IAC 5-1-37) by P.L.112-1989, SECTION 5, effective July 1, 1989.