Belize Coast Guard Application Form PDF Details

The Belize Coast Guard Application Form, officially designated as Optional OSLTF Claim Form CG NPFC-CA1 (Rev. April 03), serves a critical function within the intricate operations of the U.S. Coast Guard's National Pollution Funds Center, located at 4200 Wilson Blvd Ste 1000, Arlington, VA. This form allows individuals and entities to submit claims for compensation from the Oil Spill Liability Trust Fund for damages and removal costs resulting from oil spill incidents, as delineated by the Oil Pollution Act of 1990 (OPA). It meticulously gathers claimant information, details of the incident, types and amounts of claims, interaction with responsible parties, and legal actions taken, if any, against those parties. Additionally, the form requires disclosure of any insurance claims related to the incident, a comprehensive description of damages and how the incident caused them, efforts to mitigate damage, and witness information. An essential aspect of the completion process includes the assurance of cooperation with the U.S. in recovering compensation and a declaration of the information's accuracy under penalty of law. This form represents a crucial tool for those seeking to navigate the legal and financial aftermath of oil spills, providing a structured pathway for claims adjudication while underscoring the significant responsibilities of claimants in the process.

QuestionAnswer
Form NameBelize Coast Guard Application Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namescoast guard application form, npfc ca1 form, cg claim form, form npfc ca1 form

Form Preview Example

Department of Homeland Security

U.S. Coast Guard

ATTN: CLAIMS ADJUDICATION NATIONAL POLLUTION FUNDS CENTER US COAST GUARD STOP 7100

4200 WILSON BLVD STE 1000 ARLINGTON VA 20598-7100

Optional OSLTF Claim Form

CG NPFC-CA1 (Rev. April 03)

PURPOSE: This form may be used for submitting claims to the U.S. Coast Guard, National Pollution Funds Center, for potential compensation from the Oil Spill Liability Trust Fund for uncompensated removal costs or damages resulting from an inci- dent under the Oil Pollution Act of 1990 (OPA). You may use your own version of this form. PLEASE PRINT OR TYPE:

1. Claimant Information:

Name:

_______________________________________________________________________

 

Address:

_______________________________________________________________________

 

 

 

_______________________________________________________________________

 

 

 

_______________________________________________________________________

Home Tel. #:

____________________________

Work Tel. #: _____________________________

Fax Number:

____________________________

E-mail: _________________________________

2. Incident Information:

Date:

 

 

Time: ______________ NRC Report #:_________________

Name of vessel or facility causing damage: ____________________________________________________________________

Geographic location of incident: ____________________________________________________________________________

Brief description of the incident: ____________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

3. Type(s) of claim(s) and total amount for costs and damage(s) claimed:

$ _______________

Removal Costs

$ _____________

Subsistence Use

$

_____________

Profits & Earning Capacity

$ _______________

Public Services

$ _____________

Natural Resources

$

____________

Government Revenues

$ _______________

Real or Personal

 

 

 

 

 

 

Property

$ _______________________________

Total Amount Claimed

 

 

4.Has claimant communicated with the responsible party?

5.Has the claim been submitted to the responsible party?

No

No

Yes

Yes Date Submitted: _____________________

6. If the claim has been submitted to the responsible party, what action has the responsible party taken?

No Action

Denied

Other – Explain:

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

7. Has claimant commenced an action in court to recover costs which are the subject of the claim?

No

Yes If yes, provide the name, address, phone number of your attorney, the court in which action is

pending and the civil action number: _________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

CG NPFC-CA1 (APR 03)

Page 1 of 2

Initials/Date:

/

Previous edition can be used

 

 

 

Optional OSLTF Claim Form

CG NPFC-CA1

 

 

8. Has claimant submitted or planned to submit the loss to an insurer?

 

No

 

Yes Please provide

 

 

 

 

 

the name, address, and phone number of your insurer, the policy number, and explain any compensation received:

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

9.Description of the nature and extent of damages claimed (Attach additional information as necessary): __________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

10.Description of how the incident caused the damage: __________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

11.Description of actions taken by claimant/representative to avoid or minimize damages: ____________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

12.Witnesses:

Name: _____________________________________________ Tel. No.: __________________________________________

Address: _______________________________________________________________________________________________

______________________________________________________________________________________________

Name: _____________________________________________ Tel. No.: __________________________________________

Address: _______________________________________________________________________________________________

______________________________________________________________________________________________

13.List Documents or Attachments (Attach additional information as necessary):

a.____________________________________________________________________________________________________

b.____________________________________________________________________________________________________

c.____________________________________________________________________________________________________

d.____________________________________________________________________________________________________

e.____________________________________________________________________________________________________

I, the undersigned, agree that upon acceptance of any compensation from the Fund, I will cooperate fully with the United States in any claim or action by the United States to recover the compensation. The cooperation shall include, but is not limited to, immediately reimbursing to the Fund any compensation received from any other source for the same costs and/or damages and, providing any documentation, evidence, testimony, and other support, as may be necessary for the Fund to recover such compensation.

I, the undersigned, certify that, to the best of my knowledge and belief, the information contained in this claim represents all material facts and is true. I understand that misrepresentation of facts is subject to prosecution under Federal law (including but not limited to 18 U.S.C. 287 & 1001 and 31 U.S.C. 3729).

14. _________________________________________________

15. _______________________________________________

Claimant’s Signature

Date

Legal Representative

Date

Printed Name of Signer:

 

Title/Legal Capacity:

 

CG NPFC-CA1 (APR 03)

Page 2 of 2

Previous edition can be used

 

PRIVACY ACT STATEMENT

AUTHORITY: 33 U.S.C. 2713. PRINCIPAL PURPOSE: To aid the Coast Guard in adjudicating claims for reimbursement of removal costs and damages from oil spills when the Responsible Party has not paid. ROUTINE USES: Information on reimbursements may be provided to the Internal Revenue Service for tax purposes and may be provided to the Department of Justice for litigation against the Responsible Party. DISCLOSURE: Decision to submit a claim is voluntary; but, if proper information is not furnished by the claimant, the Government may be unable to evaluate or pay a claim.

This information applies to all claims against the Oil Spill Liability Trust Fund, whether or not the Optional OSLTF Claim Form is used.

OPTIONAL OSLTF CLAIM FORM — INSTRUCTIONS

Please provide all information, evidence, and documentation that supports the removal costs and/or damage(s) claimed. Use additional sheets or pages, as necessary, to provide information, evidence, and documentation. The following numbered paragraphs correspond to the numbers on the optional claim form:

1.Complete name, street, city, state, ZIP and phone number of the claimant (party that incurred damage and is seeking reimbursement).

2.If known, provide the following incident information on the oil spill or threat of oil spill causing or suspected of causing the removal costs and/or damage(s) claimed:

The identity of the vessel, facility or entity causing or suspected of causing the incident.

Describe the geographic area and waterway directly affected by the oil spill or threat of oil spill.

Briefly describe any known information regarding the occurrence of the oil spill or threat of oil spill.

3.Indicate the amounts by the type of claim(s) being submitted. Provide the total amount claimed.

4.Indicate if claimant has had any communication (written or verbal) with the entity causing or suspected of causing the damage(s) claimed.

5.Has the claimant or the claimant’s legal representative submitted the claim(s) to the entity causing or suspected of causing the damage claimed? If yes, include the date submitted.

6.If claim was submitted to the responsible party, indicate any response (written or verbal) or any payment you have received. Provide the date the claim was submitted.

7.Indicate if the claimant is pursing a claim(s) against the responsible party by legal repre- sentation in a court of law. If yes, provide all information that will enable us to contact your legal representative and identify your case.

* * At the bottom of the first page of the form, please initial and date the page. * *

20

8.Indicate if claimant is pursuing payment from an insurance carrier for costs that are included in the claim. If yes, provide all information that will enable us to contact the in- surer and identify the claimant’s policy.

9.Provide detailed information, evidence, and documentation that describes the extent of the damage(s) claimed. Attach copies, if necessary, of all pertinent information.

10.Provide any information, evidence, and documentation that will help describe how the oil spill, or threat of oil spill, caused the removal costs and/or damage(s) claimed.

11.Provide any information, evidence, and documentation that describe the actions of the claimant or any other person on the claimant’s behalf to reduce or avoid the damage(s) claimed.

12.Provide the name, address and telephone number (if known) of any witness to the dam- age(s) claimed. On a separate page provide a summary of each witness's knowledge of the damage(s) claimed or the incident causing or suspected of causing the damage(s) claimed.

13.If you provide additional documents, please list them here or on a separate piece of paper.

14.If the claimant is an individual, that person must sign the claim. If the claimant is a corporation, an officer of the company must sign the claim. All signatures must be in ink to be valid.

15.If the claim is presented by a legal representative, that legal representative must also sign the claim. Provide the complete address and phone number of that legal representative.

Submit your claim, with any necessary information, evidence, and documentation to:

ATTN: CLAIMS ADJUDICATION NATIONAL POLLUTION FUNDS CENTER US COAST GUARD STOP 7100

4200 WILSON BLVD STE 1000 ARLINGTON VA 20598-7100

Claims for Natural Resource Damages or for Loss of Subsistence Use of Natural Re- sources may be addressed to “ATTN: NATIONAL RESOURCE DAMAGES CLAIMS DIVISION”.

We recommend that you keep the Privacy Act Statement and a copy of the claim for your files.

21

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1. Complete your cg claim form pdf with a number of major blanks. Consider all the required information and ensure absolutely nothing is left out!

belize coast guard intake 2021 conclusion process shown (stage 1)

2. After performing this step, go on to the subsequent stage and complete all required details in all these blanks - Types of claims and total amount, Subsistence Use Profits , Natural Resources Government, Property, Total Amount Claimed, Has claimant communicated with, Has the claim been submitted to, If the claim has been submitted, No Action, Denied, Other Explain, Has claimant commenced an action, Yes If yes provide the name, pending and the civil action, and CG NPFCCA APR Previous edition.

belize coast guard intake 2021 writing process outlined (step 2)

3. This subsequent part is rather easy, Has claimant submitted or planned, the name address and phone number, Description of the nature and, Description of how the incident, Description of actions taken by, Witnesses, Name Tel No , Address , Name Tel No , and Address - all these empty fields is required to be filled in here.

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Many people often make mistakes while filling out Address in this section. Don't forget to read twice what you enter right here.

4. This particular part comes with the following form blanks to complete: Address , List Documents or Attachments, I the undersigned agree that upon, I the undersigned certify that to, Claimants Signature, Date, Printed Name of Signer, TitleLegal Capacity, Legal Representative, and Date.

Printed Name of Signer, TitleLegal Capacity, and Address of belize coast guard intake 2021

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