CG-6057 Statement of Voluntary Compliance

OMB APPROVAL 1625-0041

STATEMENT OF VOLUNTARY COMPLIANCE
Issued to verify voluntary compliance with the provisions of the Condition Assessment Scheme (CAS)
adopted by the Organization by resolution MEPC.94 (46) under the direction of the
Government of:

THE UNITED STATES OF AMERICA
By the
United States Coast Guard

Particulars of ship:
Name of ship …....………………………………………………………….………….…
Distinctive number or letters ……………………………………………………………..
Port of registry ……………………………………….……………………………………
Gross tonnage …………………………………………………………………………….
Deadweight of Ship (metric tons) …….…………………………………………………
IMO number .…………………………………………………………….….……………..
Category of Tanker ………………………………………….…………….………………
THIS IS TO CERTIFY:
1. That the ship has been surveyed in accordance with the requirements of CAS
(resolution MEPC. 94(46));
2. That the survey showed that the structural condition of the ship is in all respects
satisfactory and the ship complied with the requirements of the CAS.
This Statement of Voluntary Compliance is valid until ………….…………...............
Issued at ………………………………………………………….……………..
………….....

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Date of Issue

Commandant, (G-MOC) U. S. Coast Guard

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 report is 10 minutes. You may submit
comments concerning the accuracy of this burden estimate or any suggestions for reducing the burden to COMDT (G-MOC), U.S.
Coast Guard, Washington, DC 20593-0001 or Office of Management and Budget, Paperwork Reduction Project (1625-0041),
Washington, DC 20503.

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-6057 (11/2004)

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