I ____________________ certify to the best of my knowledge, the following information regarding my vessel is
described as follows:

Year _________ Make/Model _________________________ HIN ____________________________

1.        ( )Has not sustained any hull damages as a result of collision or grounding.

( )Has sustained hull damages as a result of collision or grounding and is described as follows: ___________________________________________________________________________________
___________________________________________________________________________________   

2.        ( ) Has not sustained any damages as a result of flooding or sinking.

 ( ) Has sustained damages as a result of flooding or sinking and is described as follows: _________________ ___________________________________________________________________________________ ___________________________________________________________________________________

3.        ( ) Has not sustained any damages as a result of fire

           ( ) Has sustained damages as a result of fire as follows: _________________________________________
            __________________________________________________________________________________
            __________________________________________________________________________________

4.   ( )  Has not been repaired as a result of warranty claim or structural failure.

           ( ) Has been repaired as a result of a warranty claim and was repaired by____________________ and

                 Described as follows:_______________________________________________________________
                                                 _______________________________________________________________

5.   ( ) Has not sustained a lightning loss.

           ( ) Has sustained a lightning loss resulting in damages and is described as follows: _____________________
               ________________________________________________________________________________
               ________________________________________________________________________________

6.        ( )Has had no major propelling engine or generator problems or rebuilds

           ( )Has had major propelling engine or generator problems or rebuilds as described as follows: ___________
               ________________________________________________________________________________
               ________________________________________________________________________________

Engine hours to the best of my knowledge is______________________

7.   ( ) Has had no peel, sand blast or grind out of osmotic blisters

           ( ) Has had peel, sand blast or grind out of osmotic blisters and prophylactic coatings described as follows:
                _____________________________________________________________________________
                _____________________________________________________________________________

8. Liens:

           ( )  My vessel is not subject to any liens.

Signature of owner:__________________ Date:______________

The above information was disclosed to the prospective buyer by the seller (prior owner) of the vessel and
said information is acknowledged as having been disclosed and taken into account for the agreed price on the above
described vessel between seller and prospective buyer.

Signature of Prospective Buyer __________________________Date___________

Witness_______________________