Section 400:9. APPENDIX IX.

APPENDIX IX.

(NOTE: Instructions in brackets are to be replaced with the relevant information and the brackets deleted.)

CERTIFICATION OF VALID CLAIM

The undersigned, as principals and as legal representatives of [insert vessel owner or operator] and [insert name and address of third party claimant] hereby certify that the claim of bodily injury [and/or] property damage caused by a sudden and/or nonsudden accidental occurrence arising from a waste deposit from [owner or operator] vessel into state waters should be paid in the amount of $[ ].

[Signatures]

Vessel Owner or Operator

Attorney for Owner or Operator

[Notary]                        [Date]

[Signature(s)]

Claimant(s)

Attorney(s) for Claimant(s)

[Notary]                        [Date]

Historical Notes

Derived from Volume 19, Issue 19, eff. July 2, 2003.

Statutory Authority

§§ 10.1-1402 and 10.1-1454.1 of the Code of Virginia.