9VAC20-170-400:9. 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]