Reinstatement REINSTATEMENT OF DOCUMENTATION Step 1 of 3 33% NOTE: FILING THIS APPLICATION DOES NOT ENTITLE A VESSEL TO DOCUMENTATION OR TO ANY CHANGES DESIRED ON A CERTIFICATE OF DOCUMENTATION. OFFICIAL NUMBERS DESIGNATED ON THE BASIS OF THIS APPLICATION ARE NOT TRANSFERABLE. ONLY A CURRENT CERTIFICATE OF DOCUMENTATION IS VALID FOR VESSEL OPERATION. IF YOUR USCG (CERTIFICATE OF DOCUMENTATION) IS PAST 30 DAYS BEYOND THE DATE OF EXPIRATION, YOU MUST REINSTATE YOUR DOCUMENTATION. A.Vessel Name (Required)*Please enter the name by which you wish the vessel to be known. If you are applying to change the vessel's name, insert the old vessel name in parenthesis. Only standard alpha and numeric characters in the vessel name will appear on the Certificate of Documentation. Please click icon for additional attachments if application covers multiple vessels.Please select from the following:I already own this vesselI purchased this vessel from another ownerThis vessel was newly builtB. OFFICIAL # (IF AWARDED)Please enter the Official Number (O/N) awarded by the Coast Guard for all but Initial Issue cases. Please confirm your official #*C. HULL ID # (IF ANY)Please enter Hull Identification Number (HIN) as assigned in accordance with 33 CFR 81.D. IMO # (IF ANY)Please enter International Maritime Organization Number (IMO), if any.E. HAILING PORT INCLUDING STATE (TO BE MARKED ON VESSEL)Please enter name of place and state exactly as it is or will be marked on the vessel. The hailing port must be a place in the United States. Commonly used abbreviations such as ‘NY, NY’ are acceptable.F. NAME OF MANAGING OWNER, E-MAIL ADDRESS, TELEPHONE NUMBER: Name, e-mail address, and telephone number of the owner to whom the Coast Guard should direct correspondence and their Social Security Number (SSN) or Tax Identification Number (TIN). Only an owner or part owner can be deemed the managing owner. For vessels owned by a corporation, the corporation is considered the managing owner. For a trust arrangement, the trustee will be the managing owner. For a Partnership or a LLC, the name of the Partnership or the LLC should be shown.NAME OF MANAGING OWNERE-MAIL ADDRESS OF MANAGING OWNER TELEPHONE NUMBER OF MANAGING OWNERSOCIAL SECURITY OR TAX ID NUMBER (46 USC 12104): (SECURE FORM)IS THIS NUMBER YOUR SOCIAL SECURITY NUMBER OR TAX ID NUMBER?SOCIAL SECURITY NUMBERTAX ID NUMBERG. PHYSICAL ADDRESS OF MANAGING OWNER (REQUIRED – 46 CFR 67.113) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Enter the mailing address. If physical (street) address differs from mailing address, enter BOTH.MAILING ADDRESS OF MANAGING OWNER (IF DIFFERENT THAN PHYSICAL ADDRESS – E.G. , P.O. BOX) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country H. Are There Other Persons / Entities That Own an Interest in the Vessel?If no, leave as is, otherwise please select yes. Include all persons and/or entities (other than managing owner) who own an interest in the vessel below.NoYesName / EntitySocial Security Number (Individual)If using a Social Security Number, please leave Tax ID Number blank.Tax ID Number (Business Entity)If using a Tax ID Number, please leave Social Security Number blank. I. PURPOSE OF APPLICATIONPlease check all applicable blocks to illustrate purpose of application. If vessel has never been documented, check Block #5 and provide ALL requested information known about the vessel's place and year of build, hull material, approximate length, and previous names and numbers. If this information is unknown, please indicate below. 1. TRANSFER/EXCHANGE OF CERTIFICATE OF DOCUMENTATION 2. REPLACEMENT OF LOST, WRONGFULLY WITHHELD OR MUTILATED CERTIFICATE OF DOCUMENTATION 3. RE-INSTATEMENT OF CERTIFICATE OF DOCUMENTATION FOLLOWING FAILURE TO RENEW 4. RETURN TO DOCUMENTATION FOLLOWING DELETION. 5. APPLICATION FOR OFFICIAL NUMBER AND FIRST CERTIFICATE OF DOCUMENTATION. VESSEL NAME WHEN LAST DOCUMENTED:VESSEL WAS BUILT AT IS UNDER CONSTRUCTION AT ATCity, State, CountryINMonth, YearIS UNDER CONSTRUCTION ATAND IS SCHEDULED FOR COMPLETION INHULL MATERIAL: WOOD STEEL FIBROUS REINFORCED PLASTIC ALUMINUM CONCRETE OTHER DESCRIBEOVERALL VESSEL DIMENSIONS:Overall Length (L):Overall Breadth (B):Overall Depth (D):PREVIOUS NAMES, NUMBERS, OR FOREIGN REGISTRATIONS OF VESSELJ. ENDORSEMENTS FOR WHICH APPLICATION IS MADEPlease check the appropriate block(s) to indicate all endorsement(s) desired on this application. RECREATIONAL FISHERY COASTWISE REGISTRY COASTWISE – BOWATERS ONLY (CERTIFICATE ON FILE) COASTWISE – OIL SPILL RESPONSE ONLY (LETTER OF QUALIFICATION ON FILE) COASTWISE UNDER CHARTER TO AN ENTITY QUALIFIED TO ENGAGE IN COASTWISE TRADE (COPY OF CHARTER ON FILE) K. PRIMARY SERVICE & HORSEPOWER: PLEASE SELECT ONLY ONE SERVICE FOR WHICH THE VESSEL WILL BE PRIMARILY USED AND INSERT HORSEPOWERCOMMERCIAL FISHING BOATFISH PROCESSING VESSELFREIGHT SHIPINDUSTRIAL VESSELMOBILE OFFSHORE DRILLING UNITOIL RECOVERYOFFSHORE SUPPLY VESSELPASSENGER (6 OR FEWER)PASSENGER (MORE THAN 6)PASSENGER BARGE (6 OR FEWER)PASSENGER BARGE (MORE THAN 6)PUBLIC FREIGHTPUBLIC TANKSHIP/BARGEPUBLIC VESSEL, UNCRECREATIONALRESEARCH VESSELSCHOOL SHIPTANK BARGETANK SHIPTOWING VESSELUNCLASSIFIED VESSELHORSEPOWER L. CITIZENSHIP OF OWNER (CHECK THE BOX(ES) TO SHOW THE TYPE(S) OF ENTITY(IES) THAT OWNS THE VESSEL)Vessel must be owned by a U.S. citizen eligible for the endorsement(s) desired. Please select the section that describes the type of entity that owns the vessel. Citizenship for all owners must be provided.INDIVIDUAL: This includes native born, as well as naturalized U.S. citizens. GOVERNMENT ENTITY: This includes Federal, State, Territory, Possession or Subdivision. CORPORATION: Please complete all items that apply. LIMITED LIABILITY COMPANY (LLC): Please complete Equity Section and choose type. For member managed LLC, a list of members is required. Please click icon for additional attachments if application covers multiple members. PARTNERSHIP: Please complete Equity Section and choose type. A list of all general partners is required. Please click icon for additional attachments if application covers multiple general partners. CORPORATIONS QUALIFIED UNDER 46 CFR 68.01 OR OWNED BY A NOT-FOR-PROFIT OIL RECOVERY COOPERATIVE: Please attach a copy of the Certificate of Compliance or Letter of Qualification issued by the Director, NVDC. JOINT VENTURE/ASSOCIATION: A list of all joint venturers/members is required. The percentage held by each does not need to be provided. Please click icon for additional attachments if application covers multiple joint venturers/members. TRUST ARRANGEMENT: All trustees must be U.S. citizens. If applicable, each beneficiary with an enforceable interest must be a citizen. A list of all trustees (save for managing owner) and beneficiaries with an enforceable interest is required. Please click icon for additional attachments if application covers multiple trustees/beneficiaries with an enforceable interest. ONE OR MORE INDIVIDUALS, I (WE) CERTIFY THAT ALL OWNERS OF THIS VESSEL ARE CITIZENS OF THE UNITED STATES GOVERNMENT ENTITY (FEDERAL, STATE, TERRITORY, POSSESSION OR SUBDIVISION) CORPORATION (SEE SECTION M, ITEM 5 WHEN APPLYING FOR A FISHERY OR COASTWISE ENDORSEMENT). LIMITED LIABILITY COMPANY (LLC) (COMPLETE EQUITY SECTION AND CHOOSE TYPE) PARTNERSHIP (COMPLETE EQUITY SECTION AND CHOOSE TYPE) CORPORATION QUALIFIED AND APPLYING UNDER 46 CFR 68.01 (BOWATERS) VESSEL OWNED OR OPERATED BY NOT-FOR-PROFIT OIL RECOVERY COOPERATIVE JOINT VENTURE OR ASSOCIATION TRUST ARRANGEMENT (COMPLETE EQUITY/STOCK SECTION) 1. STATE OF INCORPORATION2 CITIZENSHIP OF CHIEF EXECUTIVE OFFICER BY WHATEVER TITLE3. CITIZENSHIP OF CHAIRMAN OF THE BOARD4. NUMBER OF DIRECTORS NECESSARY TO CONSTITUTE A QUORUM5. NUMBER OF ALIEN DIRECTORS6. PLEASE SELECT PERCENTAGE OF STOCK OWNED BY U.S. CITIZENS ELIGIBLE TO DOCUMENT VESSELS IN THEIR OWN RIGHT, WITH THE ENDORSEMENT(S) SOUGHT ON THIS APPLICATION IN ACCORDANCE WITH 46 CFR PART 67 (SUBPART C) LESS THAN 50% 50% OR MORE: (I) 75% OR MORE (AND, AT EACH TIER, IF APPLICABLE) 75% OR MORE (AND, AT EACH TIER AND IN THE AGGREGATE (IF FISHERY), IF APPLICABLE) STATE EXACT PERCENTAGECORPORATION QUALIFIED AND APPLYING UNDER 46 CFR 68.01 (BOWATERS) I (WE) CERTIFY THAT THE CORPORATE STRUCTURE HAS NOT CHANGED SINCE ISSUANCE OF THE CERTIFICATE OF COMPLIANCE. VESSEL OWNED OR OPERATED BY NOT-FOR-PROFIT OIL RECOVERY COOPERATIVE I (WE) CERTIFY THAT THE INFORMATION ON FILE WITH REGARD TO COOPERATIVE AND ISSUANCE OF THE LETTER OF QUALIFICATION REMAINS UNCHANGED. JOINT VENTURE OR ASSOCIATION I (WE) CERTIFY THAT ALL MEMBERS OF THIS (JOINT VENTURE) (ASSOCIATION) ARE CITIZENS OF THE UNITED STATES, ELIGIBLE TO DOCUMENT VESSELS IN THEIR OWN RIGHT WITH THE ENDORSEMENT(S) SOUGHT. LIMITED LIABILITY COMPANY (LLC): (COMPLETE EQUITY SECTION AND CHOOSE TYPE) (SEE SECTION M, ITEM 5 WHEN APPLYING FOR A FISHERY OR COASTWISE ENDORSEMENT).EQUITY INTEREST OWNED BY PERSONS ELIGIBLE TO DOCUMENT VESSELS IN THEIR OWN RIGHT WITH THE ENDORSEMENT SOUGHT IN ACCORDANCE WITH 46 CFR PART 67 (SUBPART C). LESS THAN 50% 75% OR MORE (AND, AT EACH TIER, IF APPLICABLE) 75% OR MORE (AND, AT EACH TIER AND IN THE AGGREGATE (IF FISHERY), IF APPLICABLE) 50% OR MORE: (I) List of All Joint Ventures/Members (First & Last Name(s)):STATE EXACT PERCENTAGE 1. MEMBER MANAGED LIMITED LIABILITY COMPANY I (WE) CERTIFY THAT ALL MEMBERS OF THIS LLC ARE CITIZENS OF THE UNITED STATES ELIGIBLE TO DOCUMENT VESSELS WITH THE ENDORSEMENT(S) SOUGHT IN THEIR OWN RIGHT. LIST OF ALL MEMBERS (FIRST & LAST NAME(S)):OR2. LIMITED LIABILITY COMPANY NOT MANAGED BY MEMBERS AND NOT SIMILAR TO GENERAL PARTNERSHIP: PLEASE NOTE (A) & (B) MUST BE CHECKED FOR FISHERY AND COASTWISE ENDORSEMENTS; NOT REQUIRED FOR COASTWISE OIL SPILL OR COASTWISE UNDER CHARTER ENDORSEMENTS. A. I (WE) CERTIFY THAT ANY PERSON ELECTED TO MANAGE THE LLC OR WHO IS AUTHORIZED TO BIND THE LLC, AND ANY PERSON WHO HOLDS A POSITION EQUIVALENT TO THE CHIEF EXECUTIVE OFFICER, BY WHATEVER TITLE, AND THE CHAIRMAN OF THE BOARD OF DIRECTORS IN A CORPORATION, AND ANY PERSONS AUTHORIZED TO ACT IN THEIR ABSENCE ARE CITIZENS OF THE UNITED STATES B. NON-CITIZENS DO NOT HAVE AUTHORITY WITHIN A MANAGEMENT GROUP, WHETHER THROUGH VETO POWER, COMBINED VOTING, OR OTHERWISE, TO EXERCISE CONTROL OVER THE LLC STATE WHERE ORGANIZEDPARTNERSHIP (COMPLETE EQUITY SECTION AND CHOOSE TYPE) (SEE SECTION M, ITEM 5 WHEN APPLYING FOR FISHERY OR COASTWISE ENDORSEMENT) EQUITY INTEREST OWNED BY PERSONS ELIGIBLE TO DOCUMENT VESSELS IN THEIR OWN RIGHT WITH THE ENDORSEMENT SOUGHT IN ACCORDANCE WITH 46 CFR PART 67 (SUBPART C) LESS THAN 50% 75% OR MORE (AND, AT EACH TIER, IF APPLICABLE) 75% OR MORE (AND, AT EACH TIER AND IN THE AGGREGATE (IF FISHERY), IF APPLICABLE) 50% OR MORE: (I) STATE EXACT PERCENTAGE 1. GENERAL PARTNERSHIPI (WE) CERTIFY THAT ALL PARTNERS IN THIS PARTNERSHIP ARE CITIZENS OF THE UNITED STATES ELIGIBLE TO DOCUMENT VESSELS WITH THE ENDORSEMENT(S) SOUGHT IN THEIR OWN RIGHT. 2. LIMITED PARTNERSHIP I (WE) CERTIFY THAT ALL GENERAL PARTNERS IN THIS PARTNERSHIP ARE CITIZENS OF THE UNITED STATES, ELIGIBLE TO DOCUMENT VESSELS WITH THE ENDORSEMENT(S) SOUGHT IN THEIR OWN RIGHT. LIST ALL GENERAL PARTNERS (THIS IS REQUIRED)TRUST ARRANGEMENT I (WE) CERTIFY THAT ALL TRUSTEES AND ALL BENEFICIARIES WITH AN ENFORCEABLE INTEREST IN THIS TRUST ARRANGEMENT ARE CITIZENS OF THE UNITED STATES, ELIGIBLE TO DOCUMENT VESSELS WITH THE ENDORSEMENT(S) SOUGHT IN THEIR OWN RIGHT. PLEASE SELECT EQUITY INTEREST OWNED BY PERSONS ELIGIBLE TO DOCUMENT VESSELS IN THEIR OWN RIGHT WITH THE ENDORSEMENT(S) SOUGHT IN ACCORDANCE WITH 46 CFR PART 67 (SUBPART C) LESS THAN 50% 50% OR MORE: (I) 75% OR MORE (AND, AT EACH TIER, IF APPLICABLE) 75% OR MORE (AND, AT EACH TIER AND IN THE AGGREGATE (IF FISHERY), IF APPLICABLE) STATE EXACT PERCENTAGEOR VESSEL OWNED IN A TRUST ARRANGEMENT PURSUANT TO 46 USC 12111(c) (CROSS BORDER FINANCING) LIST OF ALL TRUSTEES AND ALL BENEFICIARIES WITH AN ENFORCEABLE INTEREST (THIS IS REQUIRED)M. I (WE) CERTIFY THAT: (MARK ALL THAT ARE APPLICABLE. ITEM 5. NOT REQUIRED FOR COASTWISE BOWATER ONLY, OIL SPILL, OR UNDER CHARTER ENDORSEMENTS.) Please complete as appropriate. The law imposes severe penalties for false statements against both the person (including agents) making the statement and against the vessel for which it is made. 1. I AM (WE ARE) A CITIZEN(S) OF THE UNITED STATES AND LEGALLY AUTHORIZED TO EXECUTE THIS APPLICATION IN THE CAPACITY SHOWN; 2. IN ACCORDANCE WITH 46 CFR PART 67 (SUBPART I) THE VESSEL(S) TO WHICH THIS APPLICATION APPLIES; (a) HAS (HAVE) BEEN MARKED WILL BE MARKED; (b) WILL AT ALL TIMES REMAIN UNDER THE COMMAND OF A U.S. CITIZEN, UNLESS DOCUMENTED SOLELY WITH A RECREATIONAL ENDORSEMENT; WILL NOT BE OPERATED IN A TRADE NOT AUTHORIZED BY THE ENDORSEMENT(S) ON THE CERTIFICATE(S) OF DOCUMENTATION. THE NAME(S) OF THE VESSEL(S) WILL NOT BE CHANGED WITHOUT APPROVAL FROM THE NATIONAL VESSEL DOCUMENTATION CENTER; AND I (WE) WILL PROMPTLY NOTIFY THE NATIONAL VESSEL DOCUMENTATION CENTER UPON A CHANGE IN ANY OF THE INFORMATION OR REPRESENTATIONS IN THIS APPLICATION. 3. HAS (HAVE) NOT OR 3a. HAS (HAVE) BEEN REBUILT OR SUBSTANTIALLY ALTERED SINCE LAST DOCUMENTATION; 4. THE VESSEL IS (NOT TITLED UNDER A STATE OR TITLED UNDER THE LAWS OF [INPUT]) THE VESSEL IS NOT TITLED UNDER A STATE (OR) TITLED UNDER THE LAWS OF (INPUT BELOW) TITLED UNDER THE LAWS OF:THE FOLLOWING ITEM (5.) IS REQUIRED FOR COASTWISE AND/OR FISHERY ENDORSEMENTS; HOWEVER, IT IS NOT REQUIRED FOR COASTWISE BOWATER ONLY, OIL SPILL, OR UNDER CHARTER ENDORSEMENTS. 5. U.S. CONTROL CERTIFICATION: THERE IS NO CONTRACT OR UNDERSTANDING THAT PROVIDES MORE THAN 25% OF THE VOTING POWER IN THE PARTNERSHIP, LIMITED LIABILITY COMPANY, CORPORATION, OR OTHER OWNING ENTITY EITHER DIRECTLY OR INDIRECTLY ON BEHALF OF ANY PERSON NOT A CITIZEN OF THE UNITED STATES. BY NO MEANS WHATSOEVER IS CONTROL IN EXCESS OF 25% CONFERRED UPON OR PERMITTED TO BE EXERCISED BY A PERSON WHO IS NOT A CITIZEN OF THE UNITED STATES. POTENTIAL PENALTIES FOR FALSE STATEMENTS OR REPRESENTATIONS BY OWNER OR REPRESENTATIVE: CIVIL, MONETARY, VESSEL FORFEITURE (46 USC 12151), FINE AND/OR IMPRISONMENT (18 USC 1001)AUTHORIZED SIGNATURE*SIGNATURE (TYPE FULL NAME)Signature*DATE CAPACITY (E.G., OWNER, AGENT, TRUSTEE, GENERAL PARTNER, CORPORATE OFFICER, MEMBER)APPLICATION FEES ARE NOT REFUNDABLE (46 CFR 67.500 (e)).PRIVACY ACT STATEMENT IN ACCORDANCE WITH 5 U.S.C. 553a, THE FOLLOWING INFORMATION IS PROVIDED TO YOU WHEN SUPPLYING PERSONAL INFORMATION TO THE U.S. COAST GUARD. 1. AUTHORITY. SOLICITATION OF THIS INFORMATION IS AUTHORIZED BY 46 U.S.C., CHAPTERS 121 AND 125; 46 U.S.C. APP. 802 AND 883. 2. THE PRINCIPAL PURPOSES FOR WHICH THIS INFORMATION IS TO BE USED ARE: (1) TO DETERMINE CITIZENSHIP OF THE OWNER OF THE VESSEL FOR WHICH APPLICATION FOR DOCUMENTATION IS MADE; AND (2) TO DETERMINE ELIGIBILITY OF THE VESSEL TO BE DOCUMENTED WITH THE TRADE ENDORSEMENT SOUGHT. 3. THE ROUTINE USES WHICH MAY BE MADE OF THIS INFORMATION INCLUDE RELEASE TO LAW ENFORCEMENT OFFICIALS, TO THE GENERAL PUBLIC UNDER FREEDOM OF INFORMATION ACT, AND TO PUBLISH INFORMATION ABOUT U.S. DOCUMENTED VESSELS. 4. DISCLOSURE OF THE INFORMATION REQUESTED ON THIS FORM IS VOLUNTARY, HOWEVER, FAILURE TO PROVIDE THE INFORMATION REQUESTED WILL RESULT IN DENIAL OF THE APPLICATION FOR DOCUMENTATION, WHICH MAY PREVENT THE OWNER FROM OPERATING THE VESSEL(S) IN A SPECIFIED TRADE. Nicks Product Test Price: $0.12 Reinstatement of Documentation Price: $450.00 Please select any additional services you wish to add to have processed Priority Request/Rush Processing Abstract of Title Certified Copy of COD Preferred Mortgage Satisfaction of Mortgage Priority Request/Rush Processing Price: $75.00 Abstract of Title Price: $75.00 Certified Copy of COD Price: $75.00 Preferred Mortgage Price: $185.00 Satisfaction of Mortgage Price: $145.00 Based on your submission, the following service(s) are also required:Coastwise Endorsement Price: $29.00 Fishery Endorsement Price: $12.00 PRIORITY REQUEST / RUSH PROCESSINGReason for Priority Request I (we) understand that making a false statement when applying for vessel documentation may subject the vessel to seizure by and forfeiture to the United States Government (46 USC §12151, formerly 46 USC §12122). PREFERRED MORTGAGEINSTRUMENT TYPE (CHECK ALL THAT APPLY) PREFERRED MORTGAGE CHATTEL MORTGAGE AMENDMENT ASSUMPTION SUPPLEMENT SUBORDINATION ASSIGNMENT OTHER (DESCRIBE) DescribeNAME(S) AND ADDRESS(ES) OF GRANTOR(S) (MORTGAGOR(S), ASSIGNOR(S), ASSUMING PARTY(IES), OR OTHER(S)GRANTOR. FOR PURPOSES OF THIS FORM, GRANTORS INCLUDE MORTGAGORS, ASSIGNORS, PERSONS ASSUMING MORTGAGES, PERSONS GRANTING SUBORDINATION OF MORTGAGES. LIST ALL GRANTORS AND ADDRESSES. INTEREST OWNED IN VESSEL OR HELD IN MORTGAGE AFFECTED BY ATTACHED INSTRUMENT (100% UNLESS OTHERWISE STATED)NAME(S) AND ADDRESS(ES) OF GRANTEE(S) (MORTGAGEE(S), ASSIGNEE(S), OR OTHER(S)GRANTEE. FOR PURPOSES OF THIS FORM, GRANTEES INCLUDE MORTGAGEES, ASSIGNEES, PERSON FROM WHOM MORTGAGES ARE ASSUMED, AND PERSON TO WHOM SUBORDINATION OF MORTGAGES ARE GRANTED. LIST ALL GRANTEES AND ADDRESSES.INTEREST OWNED IN VESSEL OR HELD IN MORTGAGE AFFECTED BY ATTACHED INSTRUMENT (100% UNLESS OTHERWISE STATED)Amount SATISFACTION OF MORTGAGEINSTRUMENT TYPE (CHECK ALL THAT APPLY) PREFERRED MORTGAGE CHATTEL MORTGAGE AMENDMENT ASSUMPTION SUPPLEMENT SUBORDINATION ASSIGNMENT OTHER (DESCRIBE) DescribeNAME(S) AND ADDRESS(ES) OF GRANTOR(S) (MORTGAGOR(S), ASSIGNOR(S), ASSUMING PARTY(IES), OR OTHER(S)GRANTOR. FOR PURPOSES OF THIS FORM, GRANTORS INCLUDE MORTGAGORS, ASSIGNORS, PERSONS ASSUMING MORTGAGES, PERSONS GRANTING SUBORDINATION OF MORTGAGES. LIST ALL GRANTORS AND ADDRESSES. INTEREST OWNED IN VESSEL OR HELD IN MORTGAGE AFFECTED BY ATTACHED INSTRUMENT (100% UNLESS OTHERWISE STATED)NAME(S) AND ADDRESS(ES) OF GRANTEE(S) (MORTGAGEE(S), ASSIGNEE(S), OR OTHER(S)GRANTEE. FOR PURPOSES OF THIS FORM, GRANTEES INCLUDE MORTGAGEES, ASSIGNEES, PERSON FROM WHOM MORTGAGES ARE ASSUMED, AND PERSON TO WHOM SUBORDINATION OF MORTGAGES ARE GRANTED. LIST ALL GRANTEES AND ADDRESSES.PERCENTAGE OF VESSEL MORTGAGED OR MORTGAGE ASSIGNED (100% UNLESS OTHERWISE STATED)AmountIF THE FOLLOWING INFORMATION IS UNKNOWN YOU MUST ORDER AN ABSTRACT OF TITLE UNDER ADDITIONAL SERVICES TOWARDS THE TOP OF THE PAGE. RECORDED BOOK:PageFILE/RECORDED DATE: TIME:OTHER IDENTIFYING DATA:USCG RENEWAL DOCUMENTATION ADVANCED PAYMENT OPTION*No Additional Years1 year renewal (additional $75.00)2 year renewal (additional $150.00)3 year renewal (additional $225.00)4 year renewal (additional $300.00)5 year renewal (additional $375.00)You can eliminate the possibility of late fees, as well as reinstatement fees, by paying your yearly renewal documentation in advance. Your certificate of documentation will be automatically renewed each year, for the number of years selected, by Maritime Documentation Center, a private documentation firm. NOTE: The NVDC only issues their vessel renewals for a period/duration of one year each. Your yearly certificate will be valid for one year only. You will receive one (1) Year long certificate each year, depending on how many additional years you have ordered. For each individual year of renewal a new renewal will be AUTOMATICALLY forwarded to your designated address at time of renewal(s). This may require that the vessel owner update their current address to facilitate the renewal process.Total $0.00 Authorization* I agree to pay the above total amount according to the card issuer agreement and hereby authorize the charge for the total amount above for the processing of selected USCG documents. I understand that my application will be processed in the order in which it is received by Maritime Documentation Center, a private fee for service documentation company, not owned or operated by any governmental agency. I understand that application and processing fees are non-refundable as per Maritime Documentation Center and as per 46 CFR 67.500(e) Payment Information American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name Having Trouble? Check this box to move forward without your Credit Card *My card information is not working; I would like to continue my submission and receive a call from a specialist regarding payment YOUR BILLING ADDRESS* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email* Enter Email Confirm Email Phone*(###) ###-####By clicking submit you agree to these Terms and Conditions and the above authorization of payment. By: Maritime Documentation Center | July 5, 2016
