READ BEFORE COMPLETING FORM
INSTRUCTIONS FOR COMPLETING FORM CG-1258
A.VESSEL NAME: Insert name by which you wish the vessel to be known. If 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. Click icon for attachment if application covers multiple vessels.
B.OFFICIAL NUMBER: Insert the Official Number (O/N) awarded by the Coast Guard for all but Initial Issue cases.
C.HULL ID #: Insert Hull Identification Number (HIN) as assigned in accordance with 33 CFR 81.
D.IMO #: Insert International Maritime Organization Number (IMO), if any.
E.HAILING PORT: Insert 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.MANAGING OWNER: Legal name, e-mail address and telephone number of the owner to whom the Coast Guard should send correspondence and their Social Security Number (SSN) or Tax Identification Number (TIN). SSN or TIN IS REQUIRED. Only an owner or part owner can be the managing owner. For vessels owned by a corporation the corporation is the managing owner. For a trust arrangement, the trustee is the managing owner. For a Partnership or a LLC, the name of the Partnership or the LLC should be shown.
G.ADDRESS OF MANAGING OWNER: Enter the mailing address. If physical (street) address differs from mailing address, enter BOTH.
H.NAME(S) AND SOCIAL SECURITY NUMBER(S) OR TAX I.D. NUMBER(S) OF OTHER OWNERS: All persons/entities (other than managing owner) who own an interest in the vessel. If no owners other than the managing owner, leave blank. Click icon for attachment if application covers multiple owners.
I.PURPOSE OF APPLICATION: Check applicable blocks to show 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.
J.ENDORSEMENTS: Check the appropriate block(s) to indicate all endorsement(s) sought on this application.
K.PRIMARY SERVICE & HORSEPOWER: Select only ONE service for which the vessel will be primarily used and insert horsepower.
L.CITIZENSHIP: Vessel must be owned by a U.S. citizen eligible for the endorsement(s) sought. Select the section that describes the type of entity that owns the vessel. Citizenship for all owners must be provided. See 46 CFR Subpart C for Citizenship Requirements.
INDIVIDUAL: Includes native born and naturalized U.S. citizens.
GOVERNMENT ENTITY: Includes Federal, State, Territory, Possession or Subdivision.
CORPORATION: Complete all items 1 thru 6.
LIMITED LIABILITY COMPANY (LLC): Complete Equity Section and choose type. For member managed LLC, a list of members is required. Click icon for attachment if application covers multiple members.
PARTNERSHIP: Complete Equity Section and choose type. A list of all general partners is required. Click icon for attachment if application covers multiple general partners.
CORPORATIONS QUALIFIED UNDER 46 CFR 68.01 OR OWNED BY A NOT-FOR-PROFIT OIL RECOVERY COOPERATIVE: 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 need not be shown. Click icon for attachment 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 (except managing owner) and beneficiaries with an enforceable interest is required. Click icon for attachment if application covers multiple trustees/beneficiaries with an enforceable interest.
M.CERTIFICATION: Complete as appropriate. The law provides severe penalties for false statements against both the person (including agents) making the statement and against the vessel for which it is made.
NOTE: When applying for Fishery and/or Coastwise endorsement(s), see item 5.
READ THE PRIVACY ACT STATEMENT AT THE END OF THE CG-1258.
ADDITIONAL INFORMATION ABOUT DOCUMENTATION MAY BE FOUND AT OUR WEBSITE www.uscg.mil/nvdc and in 46 CFR Parts 67, 68 and 69.
YOU MAY ALSO CONTACT OUR OFFICE AT: 800-799-8362 OR BY MAIL AT U. S. COAST GUARD,
NATIONAL VESSEL DOCUMENTATION CENTER, 792 TJ JACKSON DRIVE, FALLING WATERS, WV 25419.
DEPARTMENT OF HOMELAND SECURITY |
OMB No: 1625-0027 |
U.S. Coast Guard |
Expires: 0 /3/20 |
APPLICATION FOR INITIAL, EXCHANGE, OR REPLACEMENT OF |
|
CERTIFICATE OF DOCUMENTATION; REDOCUMENTATION |
|
NOTE: FILING THIS APPLICATION DOES NOT ENTITLE A VESSEL TO DOCUMENTATION OR TO ANY CHANGES SOUGHT 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.
COMPLETE FOR ALL APPLICATIONS
A. VESSEL NAME (REQUIRED) |
|
B. OFFICIAL # (IF AWARDED) |
|
CLICK ICON TO ATTACH LIST OF ADDITIONAL VESSEL(S) |
|
|
C. HULL ID # (IF ANY) |
D. IMO # (IF ANY) |
E. HAILING PORT INCLUDING STATE (TO BE MARKED ON VESSEL) |
|
|
|
|
F. NAME OF MANAGING OWNER |
|
SOCIAL SECURITY OR TAX ID NUMBER (REQUIRED – 46 USC 12104): |
E-MAIL ADDRESS: |
|
SSN: |
TIN: |
|
|
|
TELEPHONE NUMBER: |
|
|
|
G. PHYSICAL ADDRESS OF MANAGING OWNER (REQUIRED – |
MAILING ADDRESS OF MANAGING OWNER (IF DIFFERENT THAN |
46 CFR 67.113) |
|
PHYSICAL ADDRESS – E.G., P.O. BOX) |
H. NAME(S) OF OTHER OWNER(S) |
SOCIAL SECURITY OR TAX ID NUMBER(S) OF OTHER OWNER(S) |
|
|
|
SSN: |
TIN: |
|
CLICK ICON TO ATTACH LIST OF ADDITIONAL OWNER(S) |
|
|
I. PURPOSE OF APPLICATION |
|
|
|
|
1. 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. VESSEL NAME WHEN LAST DOCUMENTED:_____________________________
5. APPLICATION FOR OFFICIAL NUMBER AND FIRST CERTIFICATE OF DOCUMENTATION. VESSEL
|
|
WAS BUILT AT ____________________________________________________________ IN ____________________________ |
|
|
|
|
|
OR |
|
|
|
CITY, STATE, COUNTRY |
|
|
MONTH/YEAR |
|
|
IS UNDER CONSTRUCTION AT __________________________________ AND IS SCHEDULED FOR COMPLETION IN___________ |
|
|
|
|
WOOD |
|
STEEL |
|
FIBROUS REINFORCED PLASTIC |
|
ALUMINUM |
|
|
CONCRETE |
HULL MATERIAL: |
|
|
|
|
|
|
|
|
|
|
OTHER (DESCRIBE) _______________________________APPROXIMATE LENGTH OF VESSEL_______________ |
|
|
|
|
PREVIOUS NAMES, NUMBERS, OR FOREIGN REGISTRATIONS OF VESSEL __________________________________________________
J. ENDORSEMENTS FOR WHICH APPLICATION IS MADE
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 |
|
|
HORSEPOWER:__________________ |
OFFSHORE SUPPLY VESSEL |
RECREATIONAL |
COMMERCIAL FISHING BOAT |
PASSENGER (6 OR FEWER) |
RESEARCH VESSEL |
FISH PROCESSING VESSEL |
PASSENGER (MORE THAN 6 ) |
SCHOOL SHIP |
FREIGHT SHIP |
PASSENGER BARGE (6 OR FEWER) |
TANK BARGE |
FREIGHT BARGE |
PASSENGER BARGE (MORE THAN 6) |
TANK SHIP |
INDUSTRIAL VESSEL |
PUBLIC FREIGHT |
TOWING VESSEL |
MOBILE OFFSHORE DRILLING UNIT |
PUBLIC TANKSHIP/BARGE |
UNCLASSIFIED VESSEL |
OIL RECOVERY |
PUBLIC VESSEL, UNC |
|
CG-1258 (0 / ) |
Previous Edition ObsolHWH3 age 2 of 4 |
|
|
|
|
|
|
|
|
L.CITIZENSHIP OF OWNER (CHECK THE BOX(ES) TO SHOW THE TYPE(S) OF ENTITY(IES) THAT OWNS THE VESSEL)
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).
1.STATE OF INCORPORATION_____________________________
2 CITIZENSHIP OF CHIEF EXECUTIVE OFFICER BY WHATEVER TITLE___________________________
3.CITIZENSHIP OF CHAIRMAN OF THE BOARD__________________________
4.NUMBER OF DIRECTORS NECESSARY TO CONSTITUTE A QUORUM_____________________________
5.NUMBER OF ALIEN DIRECTORS______________________
6.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: STATE EXACT PERCENTAGE _____________
75% OR MORE (AND, AT EACH TIER, IF APPLICABLE)
75% OR MORE (AND, AT EACH TIER AND IN THE AGGREGATE (IF FISHERY), IF APPLICABLE)
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%
50% OR MORE: STATE EXACT PERCENTAGE _____________
75% OR MORE (AND, AT EACH TIER, IF APPLICABLE)
75% OR MORE (AND, AT EACH TIER AND IN THE AGGREGATE (IF FISHERY), IF APPLICABLE)
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.
(CLICK ICON TO ATTACH LIST OF ALL MEMBERS)(REQUIRED)
OR
2.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 ORGANIZED__________________________________
PARTNERSHIP (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%
50% OR MORE STATE EXACT PERCENTAGE _____________
75% OR MORE (AND, AT EACH TIER, IF APPLICABLE)
75% OR MORE (AND, AT EACH TIER AND IN THE AGGREGATE (IF FISHERY), IF APPLICABLE)
1. GENERAL PARTNERSHIP
I (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.
(CLICK ICON TO ATTACH LIST OF ALL GENERAL PARTNERS)(REQUIRED)
CORPORATION 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.
(CLICK ICON TO ATTACH LIST OF ALL JOINT VENTURERS/MEMBERS)(REQUIRED)
CG-1258 3 age 3 of 4
TRUST ARRANGEMENT (COMPLETE EQUITY/STOCK SECTION) (SEE SECTION M, ITEM 5 WHEN APPLYING FOR A FISHERY OR COASTWISE ENDORSEMENT)
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.
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: STATE EXACT PERCENTAGE _____________
75% OR MORE (AND, AT EACH TIER, IF APPLICABLE)
75% OR MORE (AND, AT EACH TIER AND IN THE AGGREGATE (IF FISHERY), IF APPLICABLE)
OR
VESSEL OWNED IN A TRUST ARRANGEMENT PURSUANT TO 46 USC 12111(c) (CROSS BORDER FINANCING)
I (WE) CERTIFY THAT THE VESSEL IS OWNED IN A TRUST ARRANGEMENT THAT QUALIFIES FOR A REGISTRY ENDORSEMENT ONLY PURSUANT TO PUBLIC LAW 104-324, SECT. 1136. ATTACHED IS AN AFFIDAVIT OF EACH TRUSTEE AND CITIZENSHIP EVIDENCE FOR THE CHARTERER AS REQUIRED UNDER THE STATUTE.
(CLICK ICON TO ATTACH LIST OF ALL TRUSTEES AND ALL BENEFICIARIES WITH AN ENFORCEABLE INTEREST)(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.)
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 OR 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.
HAS (HAVE) NOT OR |
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_________________________________
THE FOLLOWING ITEM 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)
_____________________________________________ |
____________________________ |
_________________________________________ |
SIGNATURE |
DATE |
CAPACITY (E.G., OWNER, AGENT, TRUSTEE, |
______________________________________________________________ |
GENERAL PARTNER, CORPORATE OFFICER, MEMBER) |
|
PRINTED OR TYPED NAME
APPLICATION FEES ARE NOT REFUNDABLE (46 CFR 67.500 (d)).
PRIVACY ACT STATEMENT
PURSUANT TO 5 U.S.C. § 552A(E)(3), THIS PRIVACY ACT STATEMENT SERVES TO INFORM YOU OF WHY THE U.S. COAST GUARD (USCG) IS REQUESTING THE INFORMATION ON THIS FORM.
AUTHORITY: 46 U.S.C. CHAPTERS 121, 125, 551 AND §50501.
PURPOSE: TO OBTAIN INFORMATION TO ESTABLISH THE ELIGIBILITY OF A VESSEL TO BE DOCUMENTED AS A “VESSEL OF THE UNITED STATES”; ENGAGE IN A PARTICULAR TRADE; AND/OR BECOME THE OBJECT OF A PREFERRED SHIP’S MORTGAGE.
ROUTINE USES: AUTHORIZED USCG PERSONNEL WILL USE THIS INFORMATION TO DETERMINE CITIZENSHIP OF THE OWNER OF THE VESSEL FOR WHICH APPLICATION FOR DOCUMENTATION IS MADE; AND DETERMINE ELIGIBILITY OF THE VESSEL TO BE DOCUMENTED WITH THE TRADE ENDORSEMENT SOUGHT. ANY EXTERNAL DISCLOSURES OF DATA WITHIN THIS RECORD WILL BE MADE IN ACCORDANCE WITH DHS/USCG-013, MARINE INFORMATION FOR SAFETY AND LAW ENFORCEMENT, 74 FEDERAL REGISTER (FR) 30305, JUNE 25, 2009.
DISCLOSURE: FURNISHING THIS INFORMATION IS VOLUNTARY. HOWEVER, FAILURE TO PROVIDE THE INFORMATION REQUESTED MAY RESULT IN DENIAL OF THE APPLICATION FOR DOCUMENTATION, WHICH MAY PREVENT THE OWNER FROM OPERATING THE VESSEL(S) IN A SPECIFIED TRADE.
AN AGENCY MAY NOT CONDUCT OR SPONSOR AND A PERSON IS NOT REQUIRED TO RESPOND TO A COLLECTION OF INFORMATION UNLESS IT DISPLAYS A VALID OMB CONTROL NUMBER.
THE COAST GUARD ESTIMATES THAT THE AVERAGE BURDEN FOR THIS FORM IS 30 MINUTES. YOU MAY SUBMIT ANY COMMENTS CONCERNING THE ACCURACY OF THIS BURDEN ESTIMATE OR MAKE SUGGESTIONS FOR REDUCING THE BURDEN TO: U.S. COAST GUARD, NATIONAL VESSEL DOCUMENTATION CENTER, 792 TJ JACKSON DRIVE, FALLING WATERS, WEST VIRGINIA 25419, OR OFFICE OF MANAGEMENT AND BUDGET, PAPERWORK REDUCTION PROJECT (1625-0027), WASHINGTON, DC 20503.
CG-1258 (0 / ) |
Page 4 of 4 |
|
|
|
