FORM C

PUNONGHIMPILAN TANOD BAYBAYIN NG PILIPINAS

(Headquarters Philippine Coast Guard)
139 25th Street, Port Area
1018 Manila

MASTER’S DECLARATION OF SAFE DEPARTURE (MDSD)

For PCG Stamp
REPUBLIC OF THE PHILIPPINES M/B REDEN JA
Vessel Name : __________________________ Cleared to depart/
Philippine Coast Guard Voyage No. : __________________________ Not Cleared to depart
CGSS
Station/Detachment ______________________________________ Date : __________________________

MANUEL BOLANTE JR
I, __________________________________ Master of M/B REDEN JA
_________________________________ presently berthed / anchored at
BINANGONAN RIZAL
_____________________________________________________ after having been duly sworn to in accordance with law, do hereby depose and state:

1. THAT my vessel is seaworthy in all respect to sail for ___________________________________________ at ____________________ hrs;

2. That I have caused the verification and inspection on my ship and I hereby attest to the following findings:
YES NO N/A
/ a) Completeness and validity of ships safety certificates and documents;
/ b) Compliance with safe manning requirement and crew certification and qualification document validity;
/ c) Officers and crew are in healthy and sound condition, not under the influence of alcohol or prohibited drugs and fit to
perform duties and responsibilities for the intended voyage;
/ d) Carriage of cargo and passengers are with authorized limits, and properly documented;
/ e) Required communications and navigational equipment are complete and in good operating condition;
/ f) Main and auxiliary engines are in good and operating condition;
/ g) Fire-fighting and life-saving appliances are complete, in good operating condition, available and accessible to
passengers;
/ h) Proper ship stability and trim, cargo stowage securing and lashings are strictly observed;
/ i) Prevailing weather conditions for intended voyage is safe and latest weather bulletin and advisory are available;
/ j) The crew, passengers and cargoes have undergone the necessary security screening;
/ k) Hull in excellent condition; and
/ l) Attached documents are properly accomplished:
YES NO N/A
/ i. Voyage Plan
/ ii. Crew List
/ iii. Passenger Main Manifest
/ iv. Passenger Supplemental Manifest
/ v. Coasting Manifest
/ vi. Dangerous Cargo Manifest and Permit to Carry Dangerous Cargo
/ vii. Cargo Manifest

3. 44 passengers and the total actual passengers on board are _______ consisting of
That the ship has an authorized carrying capacity of ______
_______adults, ________ Children and ________ infants; as per attached Passenger Main Manifest.

4. THAT I am permitted to carry the following items which are properly stowed and lashed throughout the voyage:
a) Declaration of dangerous cargo ___________________________________________________________________________
b) Permit to carry dangerous cargo is likewise attached.

AFFIANT FURTHER SAYETH NONE,

IN WITNESS WHEREOF, I have hereunto affixed my signature this _________________________ at the City/ Municipality of
BINANGONAN
_________________________________________, Philippines.

MANUELO BOLANTE JR
__________________________________________________
(Master)
09269611579
Contact Numbers for intended voyage: 1) ____________________________ BC
License No. ________________
(Mobile Phones of Master/ C/E) 2) ____________________________ MARINA
Issued by ________________
3) ____________________________ Issued on ________________

SUBCRIBED AND SWORN to before me this ______________________ at the place as indicated above.

___________________________________________________________________
(Officer Authorized to Administer Oath under Sec 41 of the Administrative Code)

Received: Date: ______________________________________

___________________________________________ Time: ______________________________________

(Signature over printed name)

Distribution: Original-PCG Copy Duplicate- Master’s File (Ship’s file)