Form FMC-131 Application for Certificate of Financial Responsibility

UNITED STATES OF AMERICA FEDERAL MARITIME COMMISSION Washington, DC 20573 www.fmc.gov Application for Certificate of Financial Responsibility

Form FMC-131 (Rev. xx/2011) OMB No. xxxx-xxxx Expires x/xx/201x

Instructions

Submit original application and Vessel Schedule for each vessel to: Federal Maritime Commission ● Bureau of Certification and Licensing ● 800 North Capitol St. NW, Washington, DC 20573
Fax (202) 523-5830

T ype of Certificate: Performance Casualty Both

1. (a) Applicant’s legal business name and trade name(s) used (provide English translation if other than English):

__________________________________________________________________________________________

__________________________________________________________________________________________

(b) Street Address: ______________________________________________________________________

__________________________________________________________________________________________

(c) Phone: ______________________ (d) Fax: ___________________ (e) email: ____________________

(f) U. S. Taxpayer Identification Number (TIN), if applicable: ____________________________________

2. (a) Applicant’s legal form of organization, i.e., corporation, partnership, limited liability company, or other form of business association:

__________________________________________________________________________________________

(b) If a corporation, Limited Liability Company, or Partnership, provide state or country in which incorporated or formed and date of incorporation or formation:

__________________________________________________________________________________________

__________________________________________________________________________________________

3. Name and address of applicant’s U.S. agent or other person authorized to accept legal service in the United States (submit statement of acknowledgement from agent or other authorized person):

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Phone: __________________________ Fax: _______________________ email: ________________________

4. Number of vessels included in application: _____ Complete and attach a Vessel Schedule for each vessel.

Use as many Vessel Schedule sheets as necessary.

5. Intended evidence of financial responsibility (check all that apply):

Insurance	Guaranty	Escrow
Surety Bond	Self Insurance (Casualty Only)	Other (explain below)

_________________________________________________________________________________________

_________________________________________________________________________________________

Declaration: I declare under penalty of perjury under the laws of the United States of America that the information provided herein is true, correct, and complete.

By: _____________________________________Date: ____________________________________________

(Signature of official)

________________________________________Address: __________________________________________

(Printed Name)

________________________________________ __________________________________________

(Title)

__________________________________________

If not a corporate officer or partner, please submit a Power of Attorney to demonstrate your authority to submit this application.

Form FMC-131 - continued Application for Certificate of Financial Responsibility Vessel Schedule

N ew Schedule Amended Schedule Check One

Instructions

Submit a Vessel Schedule for each vessel to: Federal Maritime Commission ● Bureau of Certification and Licensing

● 800 North Capitol St. NW, Washington, DC 20573
Fax (202) 523-5830

VESSEL SCHEDULE FOR __________________________________________________________________

(Name of Vessel)

Applicant: _________________________________________________________________________________

Please submit the following documents with this schedule:

1. Copy of the Certificate of Vessel Registry if not U.S. flagged or Copy of the Certificate of Documentation if U.S. flagged
2. Copy of U.S. cruise itinerary	3. Specimen copy of passenger ticket/passage contract
4. Copy of payment and cancellation policy	5. Copy of charter agreement (if any)

Previous vessel name if any: __________________________________________________________________

Number of passenger berths: _________ Total shipboard berths: _________

Please attach information showing fare structure, i.e., number of passenger berths in each price category.

Principal Codes – On the next page, provide information on all principals, indicating which of the following describes each principal. Use the letter code(s) below to identify all that apply to each principal.

A. Owner	B. Operator	C. Parent Company	D. Ticket/Contract Issuer
E. Marketing Agent	F. Charterer	G. Technical Manager	H. Other (describe)

Principal Information

Legal Name of Principal and Trade Name(s) used (provide English translation if not in English): _________________________________________________________________________ _________________________________________________________________________	Principal Code:
Street Address: ____________________________________________________________________________ __________________________________________________________________________________________
Phone: __________________________ Fax: _______________________ email: ________________________

▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬

U.S. Agent for service of process and street address (if other than agent designated by applicant in item 3 of the Form FMC-131 application):

__________________________________________________________________________________________

__________________________________________________________________________________________

Phone: __________________________ Fax: _______________________ email: ________________________

By: _____________________________________Date: ___________________________________________

(Signature)

________________________________________Telephone: ________________________________________

(Printed Name)

________________________________________

(Title)

Submit this vessel schedule for each vessel to: Federal Maritime Commission ● Bureau of Certification and Licensing ● 800 North Capitol St. NW, Washington, DC 20573
Fax (202) 523-5830

Attach continuation sheet(s) to add additional principal

Legal Name of Principal and Trade Name(s) used (provide English translation if not in English): _________________________________________________________________________ _________________________________________________________________________	Principal Code:
Street Address: ____________________________________________________________________________ __________________________________________________________________________________________
Phone: __________________________ Fax: _______________________ email: ________________________

▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬

U.S. Agent for service of process and street address (if other than agent designated by applicant in item 3 of the Form FMC-131 application):

__________________________________________________________________________________________

__________________________________________________________________________________________

Phone: __________________________ Fax: _______________________ email: ________________________

Form FMC-131 - continued Vessel Schedule Continuation Sheet for _______________________________ (Name of Vessel)

Sheet ____ of ____

Submit this vessel schedule for each vessel to: Federal Maritime Commission ● Bureau of Certification and Licensing ● 800 North Capitol St. NW, Washington, DC 20573
Fax (202) 523-5830