NANJING MARITIME COURT

STATEMENT OF CLAIM

Plaintiff:                                                     

Domicile:                                                    

Legal Representative/Person in Charge:             Post:           

Defendant:                                                   

Domicile:                                                    

Legal Representative/Person in Charge:             Post:            

Address for Service:                                            

Claims:

Facts:

Date:                  Issued by:                   (Signature)