NORD N Dampskibsselskabet “NORDEN” A/S, 49, Amaliegade, DK-1256 Copenhagen K.

Telephone + 45 33 15 04 51. Telefax + 45 33 93 15 99 Tanker. Telefax + 45 33 93 37 33 Technical.Telex 22445. E-mail: tankers@ds-norden.com. Comtext A53DK0 33. www.ds-norden.com Vessel      

Voyage no.       OFF-HIRE STATEMENT

Reason for OFF-HIRE: Comments:

Dry-docking       Repairs       Special delays       Periodical overhaul       Deviation for crew/spares       Engine stops       Pump breakdown       Cargo tanks not accepted       Cargo holds turned down       Others      

A. TIME/POS/PORT going off-hire:      

B. TIME/POS/PORT going on-hire:      

TOTAL TIME BETWEEN A + B:      

Less normal steaming (if any) between A + B:      

NETT OFF-HIRE TIME:      

BUNKER CONSUMPTION

Bunkers on board AFuel:

      M/TDiesel:

      M/T

Bunkers on board BFuel:

      M/TDiesel:

      M/T

TOTAL CONSUMPTION BETWEEN A + BFuel:

      M/TDiesel:

      M/T

Less normal consumptionFuel:

      M/TDiesel:

      M/T

NETT CONSUMPTION DURING OFF-HIREFuel:

      M/TDiesel:

      M/T

Place/date            

Chief Officer Chief Engineer Master

Surveyor Survey company

Form tk19

MT       At sea In port