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Ped if practicable) (See CLAIMS MANUAL, Enclosure 5) 2. FROM 3. GRADE OR RATE 4. SSN 5. TO 6. VIA 7. CURRENT DUTY STATION 8. AMOUNT OF CLAIM 9. STATUS OF CLAIMANT AT TIME OF DAMAGE OR LOSS (If changed since, explain.) MEMBER, USCG OR USCGR EMPLOYEE OF USCG OTHER (Specify) 10. Claim is made in the above amount for personal property damaged or lost incident to service. I hereby assign to the U.S., to the extent of any payment of this claim accepted by me, all my right, title and interes.

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